There are two health related threads already on the SC&H forum, so I pause before starting a third one here. That said, I do start this thread here because it is obvious that health care is going to be a major theme in the Presidential campaign.

We kick the thread off with Karl Rove

TAC,Marc==============

Republicans Can Win on Health Care A market-based system can give us freedom, innovation and health security.

BY KARL ROVE Tuesday, September 18, 2007 12:01 a.m. EDT

All around America, families are grappling with health-care concerns. They wonder if they'll have insurance at a price they can afford. They worry about how much out-of-pocket health costs take from the family budget. They question if they'll be able to pick their own doctor. Some feel trapped in jobs they don't like out of fear of losing their health insurance.

As the latest government-heavy plan announced by Hillary Clinton yesterday once again shows, the answers politicians offer on health care highlight the deep differences between liberals and conservatives. This is a debate Republicans cannot avoid. But it is one we can win--if we offer a bold plan. Conservatives must put forward reforms aimed at putting the patient in charge. Increasing competition will ensure greater access, lower costs and more innovation.

Liberals see the concerns of families as a failure of private insurance, and want the U.S. to move toward a government-run, single-payer model. This is a recipe for making problems worse. Socialized medicine inevitably leads to poor quality, inefficiency, rising taxes and rationing. The waiting lines and poor care that cause people from other countries to come here for treatment are not the answer.

Government can help poorer and older Americans get quality health care without sacrificing what everyone wants--the ability to choose their own doctor and health coverage that meets their family's particular needs. What reforms will do that?• Level the tax playing field. People who work for companies get a tax break on the health insurance they get from their employer. Many small business employees, farmers and the self-employed are unable to benefit from the same tax advantage, because they or their employers can't afford health insurance. It's not fair or wise to penalize people who have to pay for health insurance out of their own pockets. They should benefit from the same tax advantage employees from bigger companies get.

The mortgage interest deduction made it easier for people to own a home and all America benefited. Similarly, every worker should get a deduction for health-insurance premiums. This would ease the burden on working families and make it possible for millions more Americans to own health insurance. Some Republicans in Congress support a tax credit rather than a deduction: that's reasonable, too. A deduction or a credit puts patients in charge by helping them get private coverage that meets their needs.

• Tax-free savings for health costs. We are encouraged to save tax-free for retirement and college; we should make it easier to save tax-free for out-of-pocket medical expenses, too. Tax-free savings accounts, paired with low-cost catastrophic health insurance, make coverage affordable for working families. For example, a youth minister told me his Health Savings Account (HSA) gave his family peace of mind because they now had insurance coverage for big emergencies and could save tax-free for everyday health expenses.

That's why, in less than three years, more than 4.5 million families have set up HSAs. Some Democrats want to rein in HSAs because they fear HSAs put the individual--not government--in charge and once someone gets to pick a plan that meets their needs, they won't like being dictated to by government.

And when people see they can save money by eating better, exercising and making healthy lifestyle choices, guess what? They do. I met with workers at Wendy's Headquarters in Ohio who were eagerly taking steps to lead healthier lives because it saved them money.

• Portability. When you change jobs, you don't have to change auto insurance, but you may have to change your health insurance and even your doctor. That's important in a world where young Americans are likely to have 10 jobs before they are age 36. Too many people are locked into jobs they don't like out of fear they'll lose health coverage. The solution is obvious: People should be able to take their health insurance with them when they change jobs.

• Arming consumers through more competition. Rep. John Shadegg (R., Ariz.) argues that people should be able to buy health insurance issued by a company based in another state. Lack of interstate competition helps to explain why the same health policy costs $8,334 in North Dakota but $10,312 in South Dakota. If consumers in South Dakota could buy that North Dakota policy, prices for health insurance would go down.

• Pool risk, lower costs. Large companies get purchasing power and savings because they share risk across large numbers of employees. Sen. Mike Enzi (R., Wyo.) and Rep. Sam Johnson (R., Texas) believe small businesses should be able to join together to pool risk, too. It would mean more competition and lower costs, and more people able to afford coverage.

• Greater transparency.Today, patients rarely know what a procedure will cost or how good a clinic or hospital is, except by reputation and word of mouth. For example, a study of metropolitan hospitals found prices for services varied widely--by as much as 259%--even after controlling for geographic variations in the cost of doing business. Putting information about cost and quality in the hands of patients would lower the cost and improve the quality of health care. Patients making informed choices would create market pressures for lower prices and better care.

• Stop junk lawsuits. I've heard sad stories from doctors and patients. The doctor who had to close her clinic in her hometown and move across the state to work at a hospital that would pay her rising liability insurance premiums. The head trauma specialist afraid that when he retired, his community in one of the poorest regions in the country couldn't attract a replacement. The pregnant woman who drove 80 miles from home in Las Vegas to get prenatal care.

Communities are losing talented health-care professionals who simply can't afford the bigger liability premiums caused by frivolous lawsuits. More than 48% of all counties in the U.S. have no ob-gyn physicians. Hospitals are finding it tougher to provide obstetrics, emergency room care or neurosurgery because of frivolous lawsuits. And doctors, afraid of lawsuits, practice "defensive medicine," ordering unnecessary tests and procedures which add to the cost of health care.

• Build on the progress already made by putting patients in charge and letting competition work. When Congress considered prescription drug coverage under Medicare, Democrats tried to have government set prices and deliver the drugs. When the Congressional Budget Office estimated the first year's monthly premium for seniors would be $35, Democrats tried to lock in that price.

Republicans disagreed, arguing competition would lower prices and provide more choices. They were right: Competition led to more options and an average monthly premium of around $23--an annual savings of $144 in the first year. Competition continues to save seniors (and taxpayers) money. When the bill passed, independent actuaries estimated the monthly premium for 2008 would be $41. Recently, Medicare officials announced that the 2008 average monthly premium will be around $25. Seniors would have paid over $4 billion more in prescription drug premiums the first two years of the program had Democrats mandated a $35 monthly premium. Taxpayers are saving also: This past January, the actuaries projected that the prescription drug benefit will cost $113 billion less over the next 10 years than estimated the previous year, primarily because of competition and low bids.

In short, the best health reform proposals will be those that recognize and build on the virtues of our market-based medical system. Sick people around the world come here because they can't get quality care in their home countries. Many health-care professionals come here to practice, leaving behind well-meaning health-care systems where government is in charge, bureaucrats make the decisions, and where the patient doesn't have the choice he or she does in the U.S.Mrs. Clinton may think Americans want to trade freedom and innovation for the illusory security of government regulation and surrender control of their health decisions to government bureaucrats. My bet is 2008 will teach us something different if Republicans make health care a centerpiece issue.

Mr. Rove recently left the White House, where he was an adviser to President Bush.

The Democratic battle of health plans has begun in earnest now that Hillary Clinton has promised "universal" coverage. Meeting with Iowans a few weeks ago, John Edwards probably told voters more than they wanted to hear about what it means when government controls your health care: Under his proposed scheme, Americans could be punished for not going to the doctor for preventive care.

Mr. Edwards made clear that a government big enough to give you health care is big enough to take it away. "You have to go in and be checked and make sure that you are OK," he said. For example, women would be required to have regular mammograms or presumably lose their right to coverage.

Mr. Edwards could almost be channeling David Cameron, leader of Britain's opposition Tory party, who recently came up with his own scheme to deny free National Health Service treatment to those who fail to follow a healthy lifestyle. "Heavy smokers, the obese and binge drinkers who were a drain on the NHS could be denied some routine treatments such as hip replacements until they cleaned up their act," reports the London Standard.

Small wonder that Michael Ancram, a former deputy leader of the Conservative Party, has taken Mr. Cameron to task in a manifesto calling for a return to the party's core principles of lower taxation, skepticism about the European Union and tough anti-crime measures. He urged the party leadership to stop "trashing" the legacy of Margaret Thatcher and downplay its trendy embrace of gay unions and draconian economic curbs on carbon emissions.

Would that some brave Democrat might step forward to criticize Mr. Edwards for going further than almost anyone has in the U.S. to link government's provision of health services with the direct policing of personal behavior. In a free health-care market, personal responsibility and healthy habits would be encouraged through lower insurance premiums and other incentives. It's when the government pays the bill and controls the entire system that you can expect the heavy hand of the state to directly control your lifestyle.

HillaryCare's New Clothes Different means but the same political destination.

Wednesday, September 19, 2007 12:01 a.m. EDT

Hillary Clinton has been blasted for months by her Democratic Presidential rivals because, until Monday, she hadn't delivered her formal campaign promises for "universal" health care. But John Edwards and Barack Obama were unfair. She beat them to the punch by at least 13 years.

The former first lady's 1993-94 health-care overhaul ended disastrously. Still, it poured the philosophical and policy foundations of the current health-care debate. As she unveils HillaryCare II, Mrs. Clinton likes to joke that it's "deja vu all over again"--and it is, unfortunately. Her new plan is called "Health Choices" and mentions "choice" so many times that it sounds like a Freudian slip. And sure enough, "choice" for Mrs. Clinton means using different means that will arrive at the same end: an expensive, bureaucratic, government-run system that restricts choice.

Begin with the "individual mandate." The latest fad after Mitt Romney's Massachusetts miracle, it compels everyone to have insurance, either through their employers or the government. Not only would this element of HillaryCare require a huge new enforcement bureaucracy, it is twinned with a "pay or play" tax on businesses that don't, or can't afford to, provide health insurance to their employees. The plan also creates a new public insurance option, modeled after Medicare, and open to everyone, regardless of income. To keep insurance "affordable," HillaryCare II offers a refundable tax credit that limits cost to a certain percentage of income. Yet the program works at cross-purposes, because coverage mandates always drive up the price of insurance. And if the "pay or play" tax is lower than a company's current health insurance costs, a company will have every incentive to dump its employee plan and pay the tax.

Meanwhile, the private insurance industry would be restructured with far more stringent regulations. Mrs. Clinton would require nationally "guaranteed issue," which means insurers have to offer policies to all applicants. She would also command "community rating," which prohibits premium differences based on health status.

Both of these have raised costs enormously in the states that require them (such as New York), but Mrs. Clinton says they are necessary nationwide to prevent "discrimination" that infringes "on the central purposes of insurance, which is to share risk." Not quite. The central purpose of insurance is to price, and hedge against, reasonably predictable risks. It does not require socializing every last expense and redistributing wealth.

No liberal reform would be complete without repealing the Bush tax cuts of 2001 and 2003; Mrs. Clinton would foot the bill for her plan with this tax increase. The rest of the estimated $110 billion per year in new government spending would be achieved by "modernizing" health-care delivery and "promoting wellness," though this $35 billion in savings is speculative, if not fanciful. Further tax hikes would be required: That $110 billion is a back-of-the-envelope calculation, and Team Hillary is keeping the specifics in its pocket.

Given how poorly "universal" policies fared the last time around, who can blame them? Mrs. Clinton and Ira Magaziner headed a health-care task force with more than 500 members that eventually produced 1,342 numbing pages of proposals. It's hardly surprising this boondoggle died without so much as a Congressional vote.Yet Mrs. Clinton insisted that the public had been spooked by Rush Limbaugh, an article in a marginal political journal and advertising campaigns such as "Harry and Louise." In other words, the lessons she learned were political, not substantive. She thought she had overreached with too-sweeping changes. So she and her husband began to slice their universal health-care ambitions into smaller initiatives like the 1997 State Children's Health Insurance Program (Schip).

This is her strategy now. HillaryCare II is designed to cause minimal disruptions to current private insurance coverage in the short run, while dressing up the old agenda with slightly different mechanisms and rhetoric. Rather than fight small business, this time she is trying to seduce it with tax credits for small companies that provide insurance. Only later when costs rise will the credits shrink or other taxes rise. To court large manufacturers, like the auto and steel industries, she'll offer another, "temporary" tax credit to subsidize their health-care liabilities. Her plan, in short, is HillaryCare I in better clothes--a transitional platform to shift people to the default option, which is government insurance.

What's striking about all this is how little new thinking there is. Like the other Democratic proposals, HillaryCare II would mark another major government intrusion into health care. It would keep all of the system's current problems, most of them created by government policies, and entrench and expand them. The creativity is all in the political repackaging.

This article from today's NY Slimes could easily have gone in the Media thread as an example of liberal media bias-- witness the repeated efforts to blur the distinction between illegal and legal immigrants. It could also have gone in the immigration thread as an example of the consequences of illegal immigration. And it fits here-- this has all the makings of a political football.==========

Immigrants’ Emergency Care Is Limited by U.S. Rule

By SARAH KERSHAWPublished: September 22, 2007The federal government has told New York State health officials that chemotherapy, which had been covered for illegal immigrants under a government-financed program for emergency medical care, does not qualify for coverage. The decision sets the stage for a battle between the state and federal governments over how medical emergencies are defined.

The change comes amid a fierce national debate on providing medical care to immigrants, with New York State officials and critics saying this latest move is one more indication of the Bush administration’s efforts to exclude the uninsured from public health services. State officials in New York and other states have found themselves caught in the middle. The New York dispute, focusing on illegal immigrants with cancer — a marginal group of unknown size among the more than 500,000 people living in New York illegally — has become a flash point for health officials and advocates for immigrants in recent weeks.

Under a limited provision of Medicaid, the national health program for the poor, the federal government permits emergency coverage for illegal immigrants and other noncitizens. But the Bush administration has been more closely scrutinizing and increasingly denying state claims for federal payment for some emergency services, Medicaid experts said.

Last month, federal officials, concluding an audit that began in 2004 and was not challenged by the state until now, told New York State that they would no longer provide matching funds for chemotherapy under the emergency program. Yesterday, state officials sent a letter to the federal Medicaid agency protesting the change, saying that doctors, not the federal government, should determine when chemotherapy is needed.

Federal health officials declined to discuss chemotherapy or the New York claims. But Dennis Smith, director of the Center for Medicaid and State Operations at the federal Centers for Medicare and Medicaid Services, said in a statement, “Longstanding interpretations by the agency have been that emergency Medicaid benefits are to cover emergencies.”

The federal statute that defines an emergency under Medicaid makes it clear that routine care for illegal immigrants and nonresidents, including foreign students and visitors, is not covered. But the only procedures it specifically excludes from reimbursement are organ transplants, leaving to the states the task of further defining an emergency. States and courts have grappled with the question for years, yielding no clear definition.

Some states have maintained that any time a patient is able to schedule an appointment — as opposed to showing up at an emergency room — the condition would not be considered an emergency. Others, including New York, have defined an emergency as any condition that could become an emergency or lead to death without treatment.

“There are clearly situations that we consider emergencies where we need to give people chemotherapy,” Richard F. Daines, the New York State health commissioner, said in an interview late yesterday. “To say they don’t qualify is self-defeating in that those situations will eventually become emergencies.”

Dr. Daines said that for every effort in the state to use Medicaid “creatively” to cover the uninsured, “the Bush administration, at every chance, is pushing it back.”

The state estimated that the federal government denied $60 million in matching funds for emergency Medicaid from 2001 to 2006, including $11.1 million for chemotherapy. Medicaid costs are typically split evenly between the state and the federal government.

It is unclear how many other states are providing chemotherapy to illegal immigrants, because all emergency services are generally lumped together in state Medicaid reports. But others have also been challenged on emergency Medicaid claims.

In Washington State, where illegal immigrants are entitled to Medicaid coverage for a month or more after treatment in an emergency, officials said a federal audit of their emergency Medicaid claims was under way, and the state has asked the federal government to provide a definition of emergency services.

“The awkward position state Medicaid programs are in is trying to figure out what kinds of medical care should be available for emergency conditions,” said Douglas Porter, assistant secretary for the Washington Health and Recovery Services Administration.

Washington and other states have also fought the federal government over Medicaid for infants born to illegal immigrants, an issue reflected in the ferocious debate over the national children’s health insurance program.

In the wake of stricter federal rules, New York, New Jersey, Connecticut and 20 other states have extended full Medicaid coverage, using only state money, to some immigrants who do not qualify for federal aid. Under federal law, proof of citizenship is required for full Medicaid coverage, but not for emergency coverage.

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But some states with growing immigrant populations, like Georgia and Arizona, have themselves moved to limit coverage under emergency Medicaid, leading to intense opposition from immigrant health advocates.

Advocates for breast cancer patients said they were particularly concerned about the denial of coverage after lobbying the federal government for years to provide breast cancer screening to uninsured women. Under a program offered to underinsured and uninsured women, the Centers for Disease Control and Prevention provides free or low-cost screening.

“To allow women to be diagnosed with breast cancer and then create an obstacle for them to get treatment is a horrendous policy,” said Donna Lawrence, executive director of Susan G. Komen for the Cure in New York.

In New York City, cancer kills 15,000 residents a year. It is the second leading cause of death among both the native- and the foreign-born, according to a 2006 survey by the city’s health department, with lung, breast and colon cancer the top killers.

The state had initially accepted the federal finding that New York was not entitled to federal reimbursement for chemotherapy under the emergency Medicaid program. But until last month, state health officials had not informed medical providers that the treatment would no longer be covered by either state or federal funds.

That provoked a pitched outcry from immigrant health advocates over the last few weeks, and state health officials reversed their position this week, saying Medicaid should cover the treatment.

State officials said they were challenging the federal decision on the grounds that chemotherapy treatment qualifies as an emergency under the federal government’s own rules. Certain conditions, including diseases of the brain, spinal cord and bone marrow disease, could require immediate chemotherapy.

The state’s letter also said that chemotherapy can be used to “cure cancer, control cancer and/or ease cancer symptoms,” and that if that the measures typically used to treat cancer were not available to patients, their health could be in serious jeopardy — one of the federal criteria in determining an emergency.

The cost of emergency Medicaid is still a relatively small portion of state Medicaid budgets, experts said, and a majority of the money is spent on care for pregnant women, labor and delivery. But the demand for it rising quickly as the immigrant population balloons.

Health advocates say that many illegal immigrants who need and qualify for emergency care are afraid to seek help, and that emergency Medicaid is underused.

A recent study of emergency Medicaid services in North Carolina found that spending, largely devoted to pregnant women, increased by 28 percent from 2001 to 2004; still, the emergency costs accounted for less than 1 percent of total Medicaid expenditures.

New York City public hospitals, which serve 400,000 uninsured patients a year, among them illegal immigrants, would continue to provide the cancer treatment no matter what, said officials from the Health and Hospitals Corporation. But if there is no reimbursement from Medicaid, they said, they will have to look elsewhere for financial support.

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HillaryCare Flops in CaliforniaBy JOHN FUNDSeptember 22, 2007

SACRAMENTO, Calif. -- Hillary Clinton is patting herself on the back for proposing a health-care plan that is much more politically astute than her 1993 Rube Goldberg effort. She told an audience in New York this week: "I think I have successfully thought through all of the objections and pre-empted them."

She may want to think again. Last January, California Gov. Arnold Schwarzenegger proposed an eerily similar plan using the same rhetoric and even the same slogan adopted by Mrs. Clinton to describe hers: "Shared Responsibility."

That's no coincidence. Both ArnoldCare and HillaryCare 2.0 are the product of the same advisers. But despite all of its clever political compromises, ArnoldCare is bogged down in trench warfare in California's liberal Democratic legislature. If anything passes, it will likely be only a shell of a bill without any financing component. Legislators will hope voters approve a general tax increase to pay for it in November 2008.

The two plans have many features in common. ArnoldCare's $12 billion-a-year price tag represents about a 10th of Mrs. Clinton's estimate for the costs of her plan, roughly in line with California's share of the national economy. Both include mandates to buy health insurance, a ban on premium differences based on health status, Medicaid expansion, and a requirement that insurers have to offer policies to all applicants.

All of this is the brainchild of Laurie Rubiner, who directed health-care issues at the liberal New America Foundation until she left in 2005 to become Mrs. Clinton's Senate legislative director. She was replaced by Len Nichols, who in 1993 served as the liaison between President Bill Clinton's budget office and Mrs. Clinton's health-care task force. Ms. Rubiner isn't taking direct credit for selling Mr. Schwarzenegger on her plan, but aides to the governor confirm her role. Steve Clemons of the New America Foundation acknowledges that Ms. Rubiner "incubated and hatched" the ideas at the heart of the governor's plan. Ms. Rubiner declined to respond to a request for an interview.

Given the similarities, here are some political lessons that ArnoldCare might teach us about how Mrs. Clinton's plan might be received:

• The claim that no new bureaucracies are created will be challenged. Like Gov. Schwarzenegger, Mrs. Clinton envisions requiring everyone to prove they have health insurance. But she's vague on the details: "At this point, we don't have anything punitive that we have proposed." You can bet she will have some ideas.

Even so, making certain people have insurance is easier said than done. California has had a law mandating that drivers have car insurance since 1970 and has required physical proof of insurance to register a car for a decade. Even so, the Insurance Research Council says 25% of the state's drivers remain uninsured.

• Illegal aliens and their access to health insurance will be controversial. Mrs. Clinton promises health care for all, but is punting on the issue of whether the illegal aliens who often use emergency room services will be covered. Ms. Rubiner admits it's a "huge issue," but says "that's one we're going to have to think through a little bit."

Criticism of the governor's plans to cover illegal aliens forced him to drop the idea, but this week he fumed at those who raise such "Mickey Mouse"-type concerns. Mrs. Clinton's plan could be caught between populist forces opposing health care for illegal aliens and liberals who will insist on it.

• Hoping for bipartisan support isn't the same thing as getting it. Gov. Schwarzenegger sincerely believed he could convince Republicans to support his plan. In the end, he couldn't find anyone from either party to push his plan in the legislature. It was too tax-heavy for Republicans (his effort to call proposed tax hikes "loans" flopped) and not nearly interventionist enough for Democrats.

"The governor got significant parts of the business community to sign on, from Safeway to the Los Angeles Chamber of Commerce," one adviser to the governor told me. "But that didn't move the anti-tax Republican base."

• Nothing big passes Congress these days without bipartisan support. "The lesson from California is just how difficult it is to deal with so many players that have such disparate demands," says Dan Walters, a columnist for the Sacramento Bee. "The governor's original plan had the doctors opposing the fees it imposed on them and the nurses' union upset because it wasn't single-payer. Having all the first responders who dress in white opposing your plan isn't politically healthy."

Sen. Clinton claims she now realizes she'll need actual votes to pass something. But traces of the old Hillary remain. "I wish it were possible to just wave a magic wand and say from the White House, 'Here's what I want.' But that's not the way it works," she told the Associated Press.

The real test may be her willingness to accept some market-oriented GOP proposals such as tax-free savings accounts for health care and a curb on frivolous liability lawsuits as the price for the bipartisan support she now claims to want. Now that really would be a New Hillary.

Our theme for today comes from George W Bush: “Freedom is the desire of every human heart.”

When the president uses the phrase, he’s invariably applying it to various benighted parts of the Muslim world. There would seem to be quite a bit of evidence to suggest that freedom is not the principal desire of every human heart in, say, Gaza or Waziristan. But why start there? If you look in, say, Brussels or London or New Orleans, do you come away with the overwhelming impression that “freedom is the desire of every human heart”? A year ago, I wrote that “the story of the western world since 1945 is that, invited to choose between freedom and government ‘security,' large numbers of people vote to dump freedom — the freedom to make your own decisions about health care, education, property rights, seat belts and a ton of other stuff.”

This week freedom took another hit. Hillary Rodham Clinton unveiled her new health-care plan. Unlike her old health-care plan, which took longer to read than most cancers do to kill you, this one’s instant and painless — just a spoonful of government sugar to help the medicine go down. From now on, everyone in America will have to have health insurance.

Hooray!

And, if you don’t, it will be illegal for you to hold a job.

Er, hang on, where’s that in the constitution? It’s perfectly fine to employ legions of the undocumented from Mexico, but if you employ a fit 26-year-old American with no health insurance either you or he or both of you will be breaking the law?

That’s a major surrender of freedom from the citizen to the state. “So what?” say the caring crowd. “We’ve got to do something about those 40 million uninsured! Whoops, I mean 45 million uninsured. Maybe 50 by now.” This figure is always spoken of as if it’s a club you can join but never leave: The very first Uninsured-American was ol’ Bud who came back from the Spanish-American War and found he was uninsured and so was first on the list, and then Mabel put her back out doing the Black Bottom at a tea dance in 1926 and she became the second, and so on and so forth, until things really began to snowball under the Bush junta. And, by the time you read this, the number of uninsured may be up to 75 million.

Nobody really knows how many “uninsured” there are: Two different Census Bureau surveys conducted in the same year identify the number of uninsured as (a) 45 million or (b) 19 million. The (a) figure is the one you hear about, the (b) figure apparently entered the Witness Protection Program. Of those 45 million “uninsured Americans”, the Census Bureau itself says over nine million aren’t Americans at all, but foreign nationals. They have various health-care back-ups: If you’re an uninsured Canadian in Detroit and you get an expensive chronic disease, you can go over the border to Windsor, Ontario, and re-embrace the delights of socialized health care; if you’re an uninsured Uzbek, it might be more complicated. Of the remaining 36 million, a 2005 Actuarial Research analysis for the Department of Health and Human Services says that another nine million did, in fact, have health coverage through Medicare.

Where are we now? 27 million? So who are they? Bud and Mabel and a vast mountain of emaciated husks of twisted limbs and shriveled skin covered in boils and pustules? No, it’s a rotating population: People who had health insurance but changed jobs, people who are between jobs, young guys who feel they’re fit and healthy and at this stage of their lives would rather put a monthly health tab towards buying a home or starting a business or blowing it on booze ‘n’ chicks.

That last category is the one to watch: Americans between the ages of 18 and 34 account for 18 million of the army of the “uninsured.” Look, there’s a 22-year old and he doesn’t have health insurance! Oh, the horror and the shame! What an indictment of America!

Well, he doesn’t have life insurance, either, or homeowner’s insurance. He lives a life blessedly free of the tedious bet-hedging paperwork of middle-age. He’s 22 and he thinks he’s immortal — and any day now Hillary will propose garnisheeing his wages for her new affordable mandatory life-insurance plan.

So, out of 45 million uninsured Americans, nine million aren’t American, nine million are insured, 18 million are young and healthy. And the rest of these poor helpless waifs trapped in Uninsured Hell waiting for Hillary to rescue them are, in fact, wealthier than the general population. According to the Census Bureau’s August 2006 report on “Income, Poverty and Health Insurance Coverage,” 37 percent of those without health insurance — that’s 17 million people — come from households earning more than $50,000. Nineteen percent — 8.7 million people — of those downtrodden paupers crushed by the brutal inequities of capitalism come from households earning more than $75,000.

In other words, if they fall off the roof, they can write a check. Indeed, the so-called “explosion” of the uninsured has been driven almost entirely by wealthy households opting out of health insurance. In the decade after 1995 — i.e., since the last round of coercive health reform — the proportion of the uninsured earning less than 25,000 has fallen by 20% and the proportion earning more than 75 grand has increased by 155%. The story of the last decade is that the poor are getting sucked into the maw of “coverage” and the rich are fleeing it. And, given that the cost of health “insurance” bears increasingly little relationship to either the cost of treatment or the actuarial reality of you ever getting any particular illness, it’s entirely rational to say: “You know what? I’ll worry about that when it happens. In the meantime, I want to start a business and send my kid to school.” Freedom is the desire of my human heart even if my arteries get all clogged and hardened.

I was glad, at the end of Hillary Health Week, to see that my radio pal Laura Ingraham’s excellent new book Power To The People has shot into the New York Times Bestseller List at Number One. It takes a fraudulent leftist catchphrase (the only thing you can guarantee about a “people’s republic” is that the people are the least of it) and returns it to those who mean it - to those who believe in a nation of free citizens exercising individual liberty to make responsible choices.

Do you remember the so-called “government surplus” of a few years ago? Bill Clinton gave a speech in which he said, yes, sure, he could return the money to taxpayers but that we “might not spend it the right way”. The American political class has decided that they know better than you the “right way” to make health-care decisions. Oh, don’t worry, you’re still fully competent to make decisions on what car you drive and what movie you want to rent at Blockbusters. For the moment. But when it comes to the grown-up stuff best to leave that to Nurse Hillary.

“[T]he so-called ‘explosion’ of the uninsured has been driven entirely by wealthy households opting out of health insurance. In the decade after 1995—i.e., since the last round of coercive health reform—the proportion of the uninsured earning less than $25,000 has fallen by 20 percent, and the proportion earning more than 75 grand has increased by 155 percent. The story of the past decade is that the poor are getting sucked into the maw of ‘coverage,’ and the rich are fleeing it. And, given that the cost of health ‘insurance’ bears increasingly little relationship to either the cost of treatment or the actuarial reality of you ever getting any particular illness, it’s entirely rational to say: ‘You know what? I’ll worry about that when it happens. In the meantime, I want to start a business and send my kid to school.’ Freedom is the desire of my human heart even if my arteries get all clogged and hardened.” —Mark Steyn

GOVERNMENT“Governments are not empowered to grant rights; governments can only limit, or extinguish rights. Governments can, however, bestow gifts upon its citizens. But in order to do so, governments must first take resources from those who have earned them, and redistribute those resources to others. Hillary-care, Obama-care, Edwards-care, and every other form of socialized medicine, is inherently fraught with fraud, abuse, and corruption... If the federal government is to be involved in health care, it should be looking toward encouraging, and providing incentives for private medical care that is determined between the patient and provider. The problem is complex, and cannot be solved by any government program. Health care is certainly one of the primary areas where the principles of freedom should be observed and advanced. Any candidate, or politician, who thinks government can solve the problem better than a free market, should be rejected.” —Henry Lamb

President, Congress battle over $30 billion coverage differenceWASHINGTON - President Bush, in a sharp confrontation with Congress, on Wednesday vetoed a bipartisan bill that would have dramatically expanded children's health insurance.It was only the fourth veto of Bush's presidency, and one that some Republicans feared could carry steep risks for their party in next year's elections. The Senate approved the bill with enough votes to override the veto, but the margin in the House fell short of the required number.Senate Majority Leader Harry Reid, D-Nev., decried Bush's action as a "heartless veto.""Never has it been clearer how detached President Bush is from the priorities of the American people," Reid said in a statement. "By vetoing a bipartisan bill to renew the successful Children's Health Insurance Program, President Bush is denying health care to millions of low-income kids in America. "The White House sought little attention, with Bush casting his veto behind closed doors without any fanfare or news coverage. He was discussing it later Wednesday during a budget speech in Lancaster, Pa.Socialized medicine?The State Children's Health Insurance Program is a joint state-federal effort that subsidizes health coverage for 6.6 million people, mostly children, from families that earn too much to qualify for Medicaid but not enough to afford their own private coverage.The Democrats who control Congress, with significant support from Republicans, passed the legislation to add $35 billion over five years to allow an additional 4 million children into the program. It would be funded by raising the federal cigarette tax by 61 cents to $1 per pack.The president had promised to veto it, saying the Democratic bill was too costly, took the program too far from its original intent of helping the poor, and would entice people now covered in the private sector to switch to government coverage. He wants only a $5 billion increase in funding.Bush argued that the congressional plan would be a move toward socialized medicine by expanding the program to higher-income families.Democrats deny that, saying their goal is to cover more of the millions of uninsured children and noting that the bill provides financial incentives for states to cover their lowest-income children first. Of the over 43 million people nationwide who lack health insurance, over 6 million are under 18 years old. That's over 9 percent of all children.Veto override considerationsEighteen Republicans joined Democrats in the Senate, enough to override Bush's veto. But this was not the case in the House, where despite sizable Republican support, supporters of the bill are about two dozen votes short of a successful override.House Majority Leader Steny Hoyer, D-Md., said Democrats were imploring 15 House Republicans to switch positions but had received no agreements so far.House Minority Whip Roy Blunt, R-Mo., said he was "absolutely confident" that the House would be able to sustain Bush's expected veto.Senate Minority Whip Trent Lott, R-Miss., said Congress should be able to reach a compromise with Bush once he vetoes the bill. "We should not allow it to be expanded to higher and higher income levels, and to adults. This is about poor children," he said. "But we can work it out."It took Bush six years to veto his first bill, when he blocked expanded federal research using embryonic stem cells last summer. In May, he vetoed a spending bill that would have required troop withdrawals from Iraq. In June, he vetoed another bill to ease restraints on federally funded stem cell research.Bush's letter to Congress on insurance bill vetoWar between the states over health insurance In veto math, the magic number is 146Bush veto: A blessing or curse for Republicans?New York Times Politics

In the case of the health insurance program, the veto is a bit of a high-stakes gambit for Bush, pitting him against both the Democrats who have controlled both houses of Congress since January, but also many members of his own party and the public.The Democratic Congressional Campaign Committee launched radio ads Monday attacking eight GOP House members who voted against the bill and face potentially tough re-election campaigns next year.And Gerald McEntee, president of the American Federation of State, County and Municipal Employees union, said a coalition of liberal groups planned more than 200 events throughout the nation to highlight the issue.

We need to read beyond the title of the bill. It was not about "supporting poor children"-- it expanded coverage FAR beyond that. This bill was simply another shot fired in the Democrats attack on the remaining vestiges of the private sector in our health care.

The problem is that as far as I am aware P. Bush veto's anything that comes to Poor children or Poor folk's in general. I don't think in the past 8 year's he has shown that much Concern for the well being of the poor. Maybe I am wrong here in the fact that he has gone out of his way to better the lives of poor Americans and if he has then I must be reading the wrong report's and watching the wrong poll's

Either way a Pres. must be aware that his first duty is the duty to his people..Health, Education and Protection and none of these seem to be on any Politicans mind lol!

"Bush veto's (sic) anything that comes to Poor children or Poor folk's (sic) in general."

This simply is factually wrong. This is only the second veto of Bush's presidency. Please forgive my bluntness, but the rest of your post is mostly at variance with the facts as well. Spending under Bush has gone up massively across the board-- including to "the poor". This is not to say he doesn't have especially soft places in his heart for certain corporate interests, but the mob has been feeding at the public trough with little restraint during his presidency.

Like I said, I could be wrong but I just go off of what I read and why his rating's are at record low's and even how he is not very popular in his own Party because of the choices he makes. Be it War choices, Public choices or whatever choices the man makes they don't always seem to be the best ideas on where to put money.

I am neither a Republican nor a Democrate..I have never voted the party and only the issue , so my views are never based off I am a democrate and I must hate republican's or the other way around.

As noted in the Media thread, much of what we are given to read is not honest-- due diligence is a must! Bush's popularity and lack thereof has much to do with Iraq-- and worth noting is that Congress's ratings are distinctly worse than his!!!

Here's this:

Schip Hits the Fan

The crocodile outrage flowed fast and deep yesterday after President Bush's promised veto of the Schip bill that would have vastly expanded a federal subsidy for children's health care.

Ted Kennedy called it "the most inexplicable veto in the history of the country." Barack Obama decried a "callousness of priorities." Nancy Pelosi flirted with the edges of self-parody, saying: "President Bush used his cruel veto pen to say 'I forbid 10 million children from getting the health benefits they deserve.'"

Of course, the veto will not actually deprive any current enrollees (10% of whom are adults) of medical care. President Bush made sure of that when he signed a continuing resolution funding the program until an accommodation is reached. Count on this fact remaining little noticed amid the current political circus.

Democrats believe they have a strong shot at overriding the veto, but will wait a week or two to continue milking the controversy and to solidify a campaign issue for 2008. Of the eight House Democrats who opposed the expansion and three others who didn't vote, the leadership has already rolled five of them. That means at least 14 Republicans need to turn over as well, out of 151 in the opposition.

To that end, lobbying groups including Families USA, MoveOn.org, AARP, SEIU and AFSCME, as well as the Democratic Party, are mounting an advertising campaign targeting vulnerable Republicans, mainly in swing districts. No doubt we'll see more of the same end-of-days hysteria.

Harry Reid in particular has been trying to shame Republicans by name, singling out Rep. Roscoe Bartlett of Maryland, the only member of his delegation to vote nay. In response, Mr. Bartlett thanked Mr. Reid "for recognizing that I cast the only correct vote about Schip in the state of Maryland.... Democrats are demanding that Schip be expanded to have government-controlled, taxpayer-paid health care for millions of children who already have private health coverage."

In a soundbite, Mr. Bartlett has exactly described what the battle is all about.Political Journal WSJ

We live in an era that has seen our knowledge of medical science and treatment expand at a speed that is without precedent in human history. Today we can cure illnesses that used to be untreatable and prevent diseases that once seemed inevitable. We expect to live longer and remain active and productive as we get older. Ongoing progress in genetics and our understanding of the human genome puts us on the cusp of even more dramatic advances in the years ahead.

But for all the progress we've made, our system for delivering medical care is clearly in crisis. According to a groundbreaking 1999 report on health-care quality published by the Institute of Medicine (the medical arm of the National Academy of Sciences) as many as 98,000 Americans die every year as a result of preventable medical errors. That number makes the health-care system itself the fifth-leading cause of death in this country.

Beyond the high cost in human life, we pay a steep financial price for the inability of our health-care system to deliver consistent, high-quality care. Study after study has documented the billions of dollars spent each year on redundant tests, and the prolonged illnesses and avoidable injuries that result from medical errors. The impact ripples through our society, limiting our ability to provide health care to everyone who needs it and threatening the competitiveness of U.S. businesses, which now spend an average of $8,000 annually on health care for employees.

At the heart of the problem is the fragmented nature of the way health information is created and collected. Few industries are as information-dependent and data-rich as health care. Every visit to a doctor, every test, measurement, and procedure generates more information. But every clinic, hospital department, and doctor's office has its own systems for storing it. Today, most of those systems don't talk to each other.

Isolated, disconnected systems make it impossible for your doctor to assemble a complete picture of your health and make fully informed treatment decisions. It also means that the mountain of potentially lifesaving medical information that our health-care system generates is significantly underutilized. Because providers and researchers can't share information easily, our ability to ensure that care is based on the best available scientific knowledge is sharply limited.

There is widespread awareness that we need to address the information problem. In 2001, the Institute of Medicine issued a follow-up report on health-care quality that urged swifter adoption of information technology and greater reliance on evidence-based medicine. In his 2006 State of the Union address, President Bush called on the medical system to "make wider use of electronic records and other health information technology."

But increased digitization of health-care information alone will not solve the problems we face. Already, nearly all procedures, test results and prescriptions are recorded in digital form -- that's how health-care providers transmit information to health insurers so they can be paid for their work. But patients never see this data, and doctors are unable to share it. Instead, individuals do their best to piece together the information that they think their caregivers might need about their medical history, the medications they take and the tests they've undergone.

What we need is to place people at the very center of the health-care system and put them in control of all of their health information. Developing the solutions to help make this possible is an important priority for Microsoft. We envision a comprehensive, Internet-based system that enables health-care providers to automatically deliver personal health data to each patient in a form they can understand and use. We also believe that people should have control over who they share this information with. This will help ensure that their privacy is protected and their care providers have everything they need to make fully-informed diagnoses and treatment decisions.

I believe that an Internet-based health-care network like this will have a dramatic impact. It will undoubtedly improve the quality of medical care and lower costs by encouraging the use of evidence-based medicine, reducing medical errors and eliminating redundant medical tests. But it will also pave the way toward a more important transformation.

Today, our health-care system encourages medical professionals to focus on treating conditions after they occur -- on curing illness and managing disease. By giving us comprehensive access to our personal medical information, digital technology can make us all agents for change, capable of pushing for the one thing that we all really care about: a medical system that focuses on our lifelong health and prioritizes prevention as much as it does treatment. Putting people at the center of health care means we will have the information we need to make intelligent choices that will allow us to lead healthy lives -- and to search out providers who offer care that does as much to help us stay well as it does to help us get better.

The technology exists today to make this system a reality. For the last 30 years, computers and software have helped industry after industry eliminate errors and inefficiencies and achieve new levels of productivity and success. Many of the same concepts and approaches that have transformed the world of business -- the digitization of information, the creation of systems and processes that streamline and automate the flow of data, the widespread adoption of tools that enable individuals to access information and take action -- can be adapted to the particular requirements of health care.

No one company can -- or should -- hope to provide the single solution to make all of this possible. That's why Microsoft is working with a wide range of software and hardware companies, as well as with physicians, hospitals, government organizations, patient advocacy groups and consumers to ensure that, together, we can address critical issues like privacy, security and integration with existing applications.

Technology is not a cure-all for the issues that plague the health-care system. But it can be a powerful catalyst for change, here in the U.S. and in countries around the globe where access to medical professionals is limited and where better availability of health-care information could help improve the lives of millions of people.

profits drive accountability. accountability improves service. Improving service increases customer satisfaction.when a government apparatus is put in place without viable free market alternatives, there is no incentive to improve services and satisfy customers. Case in point: America's public schools:

Florence Nightingale's famous Notes on Nursing, published in 1859, state that "the greater part of nursing consists in cleanliness". In my edition, the foreword points out that much of Miss Nightingale's writing, excellent though it is, is now out of date. In particular, the need for cleanliness is well understood. That foreword was written in 1946.

Now it is 2007, and we learn that nurses in the hospitals run by the Maidstone and Tunbridge Wells NHS Trust told patients suffering from diarrhoea to "go in their beds". Between 2004 and 2006, 90 patients treated in those hospitals died from Clostridium difficile, and the disease was a factor in the death of a further 241.

Were it not for bad nursing, bad medical attention and bad administration, none of these patients need have died. Indeed, they would not have contracted C. difficile at all unless they had gone into hospital. So, after 150 years' advance of education, technology, prosperity and science, we have lost what Florence Nightingale taught.

It was the distressing subject of diarrhoea, indeed, that provoked Miss Nightingale to one of her most trenchant footnotes. She gave the example of how, if a bedpan with a lid were changed only once a day ("As well might you have a sewer under the room"), by a maid rather than a nurse, the problem might go undetected. he bedpan must be changed frequently, inspected, and all of it, including its lid, properly cleaned.

I notice that the Healthcare Commission's report on Maidstone says that stool charts, i.e. recorded inspections of the diarrhoea, were made in fewer than 15 per cent of cases.

Florence Nightingale adds: "If a nurse declines to do these kinds of things for her patient, 'because it is not her business', I should say that nursing is not her calling." It is a "waste of power", she says, for nurses to do things such as scouring floors, but if it needs doing, they must do it: "the true nurse-calling" puts "the good of their sick first, and second only the consideration what is their 'place'?".

The testimony of the families from the Maidstone area is that their relations who died were often humiliated, left in filth, and ignored. The weakest — the old — were treated the worst. It was a failure of systems, yes, but also of individual professionals and of common humanity.

Every year, as a journalist, I go to party conferences and hear politicians of all parties make speeches about how wonderful the National Health Service is. Gordon Brown got all weepy this year about how it saved one of his eyes.

Last year, David Cameron said that where Tony Blair had spoken of three words — "Education, education, education" — he would emphasise three letters — "N-H-S".

The point our leaders are constantly making is not medical, but moral. It is that the NHS embodies organised altruism. It proves that we, as a nation, care for one another. It makes us "the envy of the world", and it makes us good.

One naturally wants to agree. We all like to think that matters of life and death are well looked after. And most of us will have direct experience of NHS nurses and doctors who have treated us with great kindness, care and skill.

Nevertheless, the basic proposition is not true. The National Health Service is not, morally, or in any other way, the best system of healthcare in the world. Indeed, it is morally defective at its very root, because it does not — cannot — put the sick first. Until this is recognised, it cannot be reformed.

The NHS is, with our state school system, the last major survival in this country of the idea of the 1940s that government can decide what is best for us and make sure that it is done. Aneurin Bevan, who invented the thing, once said that not a bed-pan (that object again) should fall to the ground without the minister knowing about it.

A colleague of mine, who investigated alternative healthcare systems when the extreme dirtiness of many British hospitals first became an issue, went to France to compare. In hospital after hospital, he found floors so clean that you could have eaten your lunch off them. Did the Health Minister order them to clean them, he asked an administrator.

He was met with a look of incredulity. "Of course not. We run ourselves. Patients have a choice of hospital. If they do not choose us, we get no money. No hospital can survive if it is not clean."

Two weeks ago in Bournemouth, Gordon Brown was on to the subject of C. difficile, babbling about ordering "deep clean" and more than doubling the number of hospital matrons to 5,000.

"Bring back matron" has become a party conference cry, like "Bring back the rope" used to be. But matron will be only a name so long as Mr Brown (or whoever is Prime Minister) ultimately decides who should have what where.

We all know that a Minister for Industry could not possibly decide how many computers we produce or how many investment banks we should have. We all know that a Minister for Food could not wisely decree what vegetables should be sold in which shops.

But we cling to the idea that a single organisation employing 1.4 million people, with the GDP of an entire Scandinavian country, run by politicians, can meet our health needs.

Suppose Sainsbury's cold meat counter was found to have helped kill more than 300 people, would the company survive? Yet the NHS sails on, dealing death. According to a report four years ago by Professor Karol Sikora, we could save 10,000 deaths a year from cancer, just by hitting the European average; but we don't, and nobody takes the blame.

The boyfriend of the chief executive of the death-dealing Maidstone trust tells the press: "No way is she going to talk to you. Why should she?" The trust has arranged her severance pay of £250,000.

We all complain about the "target culture" that made administrators in Maidstone ignore actual human suffering before their eyes. But if you have a top-down system of healthcare, targets are the inevitable response to whatever is the latest disaster.

In this case, one of the targets was to cut waiting times in Accident and Emergency to four hours (four hours! You wouldn't put up with that to buy a cinema ticket, yet we have been brainwashed into thinking that it's not too bad for your child with a broken arm). In this world without choice, each claim of need jostles against another: either faster A&E, or cleaner bed-pans, but not both.

This is all, morally, wrong. It turns the patient from being the entity for which the service exists into a nuisance. Each new patient is just an added cost and each dead patient is an administrative convenience.

Under systems of social insurance, such as exist in Germany, Belgium or France, many problems remain, but this most basic one disappears. Money goes with each patient, who can choose who treats him. Therefore every doctor, hospital and nurse wants patients.

Our system also turns the nurse and doctor away from their duty, and therefore attacks their moral sense. It tells them to ignore "the habit of observation", which, said Florence Nightingale, was the key skill of nursing, in favour of through-put or targets or — for human nature reasserts its worse side when badly led — sneaking off home exhausted and disillusioned.

The NHS is run from top to bottom, and therefore, from top to bottom, it is bad.

'As major employers, we are engaging in one of the most crucial domestic policy debates of our time -- fixing our nation's health-care crisis, reducing out of control costs, and ensuring every American has affordable health care," said CEO Steve Burd of Safeway, a supermarket chain, earlier this year.

He's not alone. Several American business leaders have come to believe that the American health-care system is not only bad for our health but also for national competitiveness. In the automotive industry, General Motors claims that it spends about $1,600 per car on health care. In Japan, according to GM, Toyota's per automobile healthcare expenditure is just $110.

Some politicians and executives have concluded that the "solution" to this problem is universal, government-run health care. They must be onto something, right?

Health coverage is indeed becoming more expensive for businesses. Over the past eight years, the percentage of firms offering health benefits to employees has dropped significantly, to 60% from 69%.

This decline, however, is almost completely accounted for by businesses with fewer than 10 employees.

These firms find health benefits unaffordable because states have laid a massive burden of over-regulation on small-group health insurance since the early 1990s, making it increasingly expensive. In the face of this, the freedom to contract employment without health benefits provides a valuable option for American entrepreneurs and workers. Only in the U.S. can they opt out of the government-regulated health "system," if it allows them to be more competitive.

But what about the share of Gross Domestic Product (GDP) spent on health care, a metric of health system performance and value that some consider definitive? The United States leads the pack in this regard, spending far more on health than other countries. Surely this puts the U.S. at a competitive disadvantage, doesn't it?

No: It's the other way around. America's high productivity gives us the ability to spend more on health care, especially the latest treatments and technologies, than other developed nations that labor under forms of socialized health care.

Robert L. Ohsfeldt and John R. Schneider of the American Enterprise Institute have determined that health spending increases at a constant rate of about 8% for every $1,000 increase in GDP per capita. For example, if GDP rises from $30,000 per capita to $31,000, health spending increases by $232. But if GDP per capita rises from $40,000 to $41,000, health spending increases by $500.

Thus, because Americans earn so much more than people in other countries, it naturally follows that we spend more on health care.

Consider four countries whose health-care systems are often held up as admirable alternatives: Canada, Germany, France and Great Britain. Certainly, the U.S. spends significantly more on health care than those countries do, but these nations also earn significantly less income per person.

Look at it this way: Even after paying for our health care, Americans have far more money left over than their neighbors to spend on other goods and services. It works out to about $8,000 more than the average German or Frenchman, and about $4,000 more than the average Canadian or Briton.

Of course, averages obscure many harsh realities and hide the fact that many Americans are unable to afford health care.

To improve the state of American health care and lighten the burden on business and workers, policy leaders should push for portability of health benefits, transparent pricing for health services, tort reform and more competition among both insurers and providers.

Crusaders for "universal" health care allege that America's unique lack of government-mandated coverage is a handicap to the nation's competitiveness. Given America's superior economic performance, however, it is a uniqueness we should not rush to abandon.

Mr. Graham is the director of health care studies at the Pacific Research Institute.WSJ

In 1799, doctors likely hastened the death of George Washington by draining a third of his blood to treat a bacterial infection. Bleeding was a common practice in those days, it dates back to the Greeks and Romans.

But nowadays, if a doctor used bloodletting he would be barred from practicing medicine. In the age of the Internet, is it any less inexcusable that we have yet to modernize and transform our health-care system?

We have talked long enough about using technology to cut costs and improve the quality of care. Now is the time to act -- and the place to start is preventable medication errors.

According to the Institute of Medicine, Americans average one medication mistake for every day spent in a hospital, accounting for more than 1.5 million injuries each year. Medication errors will kill at least 7,000 Americans this year. Of the more than three billion prescriptions written each year, doctors report nearly one billion require a follow-up between providers and pharmacies for clarification. The cost to our health-care system is in the billions.

One reason for this mess is that 95% of prescriptions are transmitted using 5,000-year-old technology: pen and paper.

That is unacceptable. The deaths and inefficiencies of paper prescriptions can be nearly entirely eliminated if we use the same technology we that use in other aspects of our lives. Electronic prescriptions can replace handwritten, misread and mismatched prescriptions with online, automated and expert technology.

The benefits are clear and compelling. When a doctor "writes" an electronic prescription, a computer can warn of potentially dangerous interactions with other medications or allergies and thereby prevent thousands of unnecessary hospitalizations each year. E-prescribing can also let a physician know whether a drug is covered by a patient's insurance or whether an alternative generic is available at a fraction of the cost. One initiative led by Chrysler, General Motors and Ford to encourage doctors to write e-prescriptions in the Detroit region has generated more than one million prescription alerts that have saved lives and money.

The benefits of e-prescribing are so important that the Institute of Medicine has called for every doctor and nurse to prescribe electronically by the year 2010. Business and labor leaders, health insurers and consumer advocates are unanimous in their support of this common-sense initiative.

Doctors also know that e-prescribing is vital for our health-care system. One recent study of 400 physicians found that 85% of physicians think e-prescribing is a good idea; 81% say it would reduce medication errors; and 65% say it would save time. They like a system that reduces their liability and allows them to focus on providing care, not filling out paperwork.

The problem is that very few doctors use the technology. Of those 400 physicians polled, only 7% actually transmit prescriptions electronically. And 63% say implementing the technology is not a priority. Why? It's not always in their immediate financial interest to do so.

That must change.

The federal government can lead by requiring that doctors who do business with Medicare convert to e-prescribing. This can be done by using market forces and the federal government's purchasing power to align financial incentives.

First, offer bonus payments to Medicare doctors who already prescribe electronically or who adopt the technology. Such payments will help doctors, especially those with small practices without many patients, to pay for startup costs. Private insurers, like WellPoint, are already using this strategy to drive adoption of e-prescribing.

If a majority of doctors don't e-prescribe a few years down the road, the government should require all doctors to adopt e-prescribing or face financial penalties. E-prescribing should become a condition of doing business with Medicare. This is no different than the requirements other suppliers expect to see when they negotiate with customers.

A new study by the Department of Health and Human Services estimates that if 18% of doctors in Medicare adopt e-prescribing, the government will save $4 billion and nearly three million adverse drug events can be prevented over five years.

This is something Republicans and Democrats can agree on. While we continue to debate how to cover the uninsured, improve quality, and lower costs, there is too little being done to modernize health care. E-prescribing for Medicare is just the beginning of the modernization and digitization our ailing health-care system urgently needs. A high-tech, healthier future is within our grasp. We just need creative leadership bold enough to reach for it.

Mr. Kerry, a Democrat, is a senator from Massachusetts. Mr. Gingrich, a Republican, is former speaker of the House and founder of the Center for Health Transformation. Chrysler, GM, Ford and WellPoint are members of the center.

America, a nation prone to love at first sight with seductive health-care fixes, is now falling for the systems of the Netherlands and Switzerland. Their representatives recently displayed their dowry in D.C., and U.S. Health and Human Services Secretary Michael Leavitt personally checked out the potential brides earlier this month.

Beware: The last time we fell in love, it was with managed care, as exemplified by California's Kaiser Permanente. But the Kaiser model proved difficult to replicate outside of California, even for Kaiser itself. The version of managed care we got was of the "Just Say No" variety: "No" to enrollee requests and provider referrals. It has made a mess of our health-care system.

Though media accounts lump the systems of Switzerland and the Netherlands together, they are profoundly different. There are things to be learned from each, though neither presents a complete model the U.S. should emulate.

The Swiss and Dutch systems share one terrific feature -- universal coverage. Americans increasingly want this. Both achieve universal coverage using private sector insurers, at far lower cost than the U.S. -- 12% of GDP for Switzerland and 10% for the Dutch, versus a staggering 15% for the U.S. in 2003. They also have far better health outcomes than the U.S., even when Switzerland is compared to socio-demographically similar U.S. states such as Connecticut and Massachusetts. The sick in both countries can afford to buy health insurance, and also pay the same price. Yet private insurers compete in the market because they are paid more for sick enrollees through various risk-adjustment systems.

But the devil is in the details.

The Swiss are required to buy health insurance themselves, using their own money -- they account for 65% of health care expenditures. If individuals cannot afford it, most Cantons transfer funds to them. There are neither employer nor government health-insurance programs for the poor or elderly. The Swiss government accounts for only a quarter of the health-care spending versus nearly 50% for the U.S.

The Swiss system is consumer-driven because consumers themselves pay for their purchases. The Dutch government, in contrast, funds consumers to purchase their own health insurance to a much greater extent -- five million people in the country are on some sort of government dole. Thus, when the Dutch buy their insurance, they may think they are using other people's money.

The results? The Swiss have lower health-care inflation -- 2.8% versus 4.1% for the Dutch and the U.S. from 1996-2003 -- and substantially more in the way of health-care resources. And Switzerland tops the world in most measures of user satisfaction.

The 93 private insurance companies that compete in Switzerland dwarf the 41 in the Netherlands. Swiss providers also compete because, in addition to paying for their health insurance, the Swiss pay for nearly 32% of their health-care services out of their own pockets, as compared with only 8% for the Dutch. Yet even with its limitations, Dutch health-care inflation fell from the time when Dutch employers bought health care, and waiting lists have reportedly tumbled.

Nevertheless, the Swiss system is hardly perfect. On the demand side, the government limits insurance competition with requirements for extensive minimum benefit packages and considerable micromanagement of prices. Imagine a car market in which the government designs the vehicles and stringently oversees distributors' prices. Pretty soon all the cars would come with features we do not necessarily want -- heated seats -- at a price we do not want to pay.

Even worse is the Swiss government's micromanagement of medical care suppliers. Unwisely adopting the U.S. government's Medicare payment system, it not only dictates medical care prices but also specifies the bundles of care for which it will pay. This kind of micromanagement discourages innovation. For example, when Duke Medical Center lowered the costs of treating congestive heart patients by 40% in only one year with innovations that improved health status, it lost nearly all the savings it created. The U.S. government pays only for activities like hospital stays and doctor visits. Perversely, medical innovators who improve health and reduce hospital visits, lose money.

So before we latch on to the Dutch or Swiss models, let's be careful. Yes, the consumer-driven health care of these two nations is clearly the better model for implementing universal coverage. But their governments' micromanagement of the prices of insurers and providers should be avoided, not emulated. Instead, government should help lower-income people, enforce transparency, prosecute fraud and abuse -- but otherwise get out of the way.

Ms. Herzlinger is professor of business administration at Harvard Business School and a senior fellow at the Manhattan Institute. She is the author of "Who Killed Health Care?" (New York: McGraw-Hill, 2007).WSJ

I am left wondering if PC cowardice accounts for this article's failure to mention the role of illegal aliens in overwhelming emergency departments. Notice how most/all of the examples given are from places like Tucscon AZ.===================

Seriously ill suffer as relationship between physician and hospital unravels By Christopher Lee The Washington Postupdated 12:39 a.m. MT, Fri., Dec. 21, 2007Hospital emergency departments across the United States, already struggling with overcrowding and growing patient loads, are increasingly unable to find specialists to help treat seriously injured and ill patients, according to medical experts.

Crucial minutes, hours and even days can go by as patients suffering from trauma, strokes, broken bones and other maladies await evaluations by neurologists, orthopedic surgeons and other specialists because hospitals are having difficulty getting them to serve 24-hour emergency "on-call" shifts.

"It can mean death," said Linda Lawrence, president of the American College of Emergency Physicians and a practicing emergency department doctor in California. "Patients have died in transport, or waiting to find a neurosurgeon, or getting to a heart center for a cardiologist."

A nationwide survey by the American College of Emergency Physicians in 2005, the most recent available, found that of the 1,328 emergency department directors who responded, 73 percent said they had a problem with inadequate on-call coverage by specialists, including neurosurgeons, orthopedic surgeons and obstetrician/gynecologists. That was up from 67 percent in 2004.

Stretched to breaking point

The shortage comes at a time when emergency rooms at many hospitals are routinely stretched to the breaking point. The annual number of visits to emergency departments rose 18 percent, to 110 million, from 1994 to 2004, according to the Centers for Disease Control and Prevention. At the same time, the number of hospitals operating 24-hour emergency departments fell by 12 percent.

The shortage of specialists is the result of a fear of malpractice lawsuits, a reluctance to go without pay when seeing uninsured patients, and a growing intolerance for the disruption in their personal lives and private practices, the experts say. Many specialists are also decreasing their work for general hospitals.

Retiree Mary Jo McClure, 74, experienced the problem firsthand one Friday afternoon in January when she fell down some concrete steps, tearing large chunks of flesh from one leg. The plastic surgeon on call for Tucson Medical Center refused to leave her private-practice patients to come to the emergency department to treat McClure, who has health insurance. The doctor said instead she would see the injured woman in her office the next Monday.

But over the weekend, the specialist telephoned the family to say that she could not treat McClure after all because she performs only cosmetic procedures and is not trained to handle severe wounds, McClure said.

"What was she doing on the roster?" asked McClure, who searched for six days before finding a plastic surgeon at another hospital who would see her. "Do they expect you to walk in for a face-lift? . . . That was a very bad day, because you are hurt and you're in pain, and you always feel like the hospital will help you."

'A constant issue'

Judy Rich, the hospital's executive vice president and administrator, said the plastic surgeon later acknowledged that she should have seen McClure.

"It's a constant issue, our emergency room coverage," Rich said. "We count on the medical staff to come in when they are called. . . . There's too many patients and not enough specialists many times in communities, and Tucson, I think, is pretty typical of the kind of dilemma that we have."

In the Washington area, specialists are generally available, but emergency room patients sometimes must be transferred to get the expert care they need, said Eric Glasser, assistant chief of the emergency department at Georgetown University Hospital.

"At Georgetown, we take referrals from the whole region, because some hospitals can't find a neurosurgeon," said Glasser, president of the D.C. chapter of the emergency physicians' group. "They have to be transported long distances when minutes count. And that, in turn, impacts overcrowding in our hospitals."

For the most part, the dearth of specialists nationally arises not from a numerical shortage but from the growing unwillingness of many specialists to take on-call duty, said Ann S. O'Malley, a physician and senior researcher who co-authored a new study of the issue for the District-based Center for Studying Health System Change.

'Unraveling'

Traditionally, many specialists agreed to pull on-call duty in exchange for admitting privileges and use of a general hospital's facilities to perform operations and other procedures as part of their regular practice, O'Malley said. But the rise of physician-owned specialty hospitals and outpatient surgical centers over the past 15 years has reduced doctors' reliance on the general hospital.

"The historic relationship between physicians and hospitals is unraveling," O'Malley said.

Another factor is the rising number of the uninsured, with specialists complaining that they often do not get paid for treating patients they see in the emergency room. Moreover, rising malpractice insurance costs and the threat of lawsuits have made more physicians reluctant to see such patients, with whom they have no established professional relationship. Because taking on-call duty can require trips to the emergency department at any hour, it can disrupt doctors' personal lives and force them to reschedule appointments or elective surgeries for their regular, paying patients.

"It's our responsibility to take care of these patients, because that's what we do. That's part of our inherent fiber of being an orthopedic surgeon," said Leon S. Benson, a hand surgeon near Chicago who is active in the American Academy of Orthopaedic Surgeons, a professional association. "But there's no question that as the inconvenience and fatigue and poor compensation and difficulty in having appropriate resources to take care of patients build up, you get this perfect-storm effect where more and more people are thinking, 'Gee, I don't know if I want to do that anymore.' "

Benson, 47, an associate professor of clinical orthopedic surgery at Northwestern University, takes emergency department on-call duty every other day, but he acknowledged that he is the exception these days.

'System is being pressured'

"I can understand nationally why this is becoming a bigger issue, because the system is being pressured," he said. "More volume is getting through a pipe that's getting smaller in diameter. And then what you actually do while you're on call gets to be more and more painful."

Some hospitals have taken steps such as hiring specialists full time or on contract, covering professional fees for doctors who see uninsured patients, and paying physicians daily or monthly stipends for on-call duty, said O'Malley, the analyst. That helps, Benson said, but hospitals might impress physicians more by setting aside trauma rooms and teams of people to assist the on-call specialist in a timely, efficient way when an emergency arises.

The shortage of on-call specialists is so dire at Covenant Medical Center in Lubbock, Tex., that the hospital sometimes has to haul out telemedicine equipment that enables neurologists in faraway cities such as San Antonio to evaluate possible stroke victims through a video link, said Juan Fitz, associate director of the emergency department.

Sarah Thompson, 29, an emergency medical technician at Covenant, said she had to be admitted to the hospital for six days in September before doctors could find an oral surgeon to evaluate a swelling in her jaw and neck. It turned out to be cat-scratch fever that caused swollen lymph nodes and a secondary infection, not an abscessed tooth, as doctors first suspected, she said.

"They had an oral surgeon on call, but he wouldn't come to see me," said Thompson, who was pregnant. "He was supposed to be taking call. And then they called him, and they said he was out of town. It was a big mess-up. . . . All of our doctors were very frustrated with the situation. They tried their best."

Lawrence, the president of the emergency physicians' group, said that legislation introduced this year on Capitol Hill -- but not yet considered in committee -- would create a bipartisan national commission to study challenges related to the provision of emergency medical services, including the on-call specialist problem.

"Something people don't understand is that even if you have insurance, if I don't have an on-call orthopedic surgeon, I can't help you," Lawrence said. "It's an issue that affects everybody, insured and uninsured. If there's no bed available, there's no bed available."

Equity and Health CareFebruary 4, 2008; Page A14Democrats, and even a few Republicans, are in a populist mood, and fair enough. But if they really want the tax code to be more "progressive" -- i.e., from each according to his means -- they ought to forget the Bush tax cuts and address the way the government subsidizes health insurance. On the advice of our doctors, we're not holding our breath.

According to the Democratic consensus, too many people lack health insurance, and the liberal remedy is to protect the status quo while expanding public programs for the uninsured. That's the opposite of a rational health policy: Not only does the current system cause unnecessary problems for the insured, but many of the gaps in coverage owe to the way tax subsidies shortchange the uninsured, particularly working-class and middle-income families.

If such inequality and unfairness existed anywhere other than health care, the Democrats would be raising hell. Instead, they're silent -- which is politically telling.

The core problem is that people who get insurance through their employers pay no income or payroll taxes on the value of the benefit. The Treasury defines this as a "tax expenditure," meaning it's revenue the government forgoes to encourage certain behavior. If these losses were converted to the equivalent of direct spending, the tax exemption would have cost more than $208 billion in 2006. The only federal programs that cost more are Social Security, Medicare and national defense. But all that money props up only employer-provided insurance. Individuals who buy policies don't get any tax breaks and pay with after-tax dollars.

If the purpose of health-care reform is to decrease the ranks of the uninsured, these job-related tax breaks are poorly targeted, even regressive. The more generous the employer health plan, the more the subsidies increase. On average, lower-wage workers have more limited coverage as part of their compensation, usually from small- or medium-sized businesses. Estimates show that the subsidy is worth more than $3,000 for upper-income families (with higher marginal tax rates), and less than $1,000 for those on the lower income rungs.

These aren't new insights, and economists have recommended changing these incentives for decades. What's hard to believe are the convenient blind spots of the Democratic Presidential candidates. Hillary Clinton, queen of the wonks, includes in her health-care proposal an undefined cap on the deduction for "high-income Americans," but all of her emphasis is on larger spending subsidies. Barack Obama doesn't even mention it. Neither did John Edwards.

They're uncharacteristically missing a chance to effectively raise taxes on "the rich." Curbing these subsidies could generate billions for their elaborate "universal" health programs. More to the point, this is a simple matter of equity, usually Democratic terrain. If the government is going to support health insurance, then those subsidies ought to apply regardless of a person's income, where they work, or how they purchase their insurance.

So why the Democratic silence? Perhaps it's because they think such a change would interfere with their main policy goal, which is slow but steady progress toward government control of the health-care market. Or possibly it's because many of the most generous tax-subsidized health plans come from union-negotiated contracts. Or maybe Democrats simply don't want to concede that President Bush has a point.

In his 2007 State of the Union address, Mr. Bush suggested redistributing the government's health subsidies. His proposal would sever the link between insurance and employment, shifting the deduction to individuals and capping it at $15,000 a year for a typical family. About four-fifths of the country would do better than they do now, while the rest currently have the most gold-plated employer coverage and would still have plenty of options.

Not only would this be a relatively cost-effective way to increase coverage. It would also address the major market distortions that the employer-exclusive deduction causes, with individuals essentially prepaying for routine costs through third-party insurance companies. If Republican candidates came to their senses, they'd recognize an opportunity to poach a traditionally Democratic issue -- as well as an opening to address middle-class anxiety without demagoguing business or "the rich." Individual policies would also be portable when workers are between jobs, reducing risk and uncertainty.

But the big questions are for the Democrats, who claim to believe that health-care reform is as much a moral as an economic issue. Whatever their other ambitions, how can they stand by a system that offers the least assistance to the working class and nothing at all to the uninsured?

The Wages of HillaryCareFebruary 7, 2008Hillary Clinton and Barack Obama agree on most policy issues, but that makes their rare differences all the more revealing. To wit, their running scrap over Mrs. Clinton's "individual mandate" for health care, which Mr. Obama has now had the nerve to expose for its inevitable government coercion.

Mrs. Clinton's proposal requires everyone to buy health insurance, along with more insurance regulation, a government insurance option for everyone and tax hikes. Mr. Obama likes all that but his mandate would only apply to children. He argues that the reason many people aren't insured is because it's too expensive, not because they don't want it. Mrs. Clinton counters that coverage can't be "universal" without a mandate.

But then Mr. Obama had the impudence to defend his views. His campaign distributed a mailer in key primary states that claimed the Clinton plan "forces everyone to buy insurance, even if you can't afford it." It also featured an image of an anxious couple at a kitchen table. The Clinton apparat went apoplectic, claiming the flyer evokes the famous "Harry and Louise" commercials. A common article of liberal faith is that this "smear campaign" doomed HillaryCare in 1994 -- as opposed to, say, its huge cost and complexities. But never mind.

Yet if Mrs. Clinton's plan is better because it has a mandate, how does it work in the real world, where some people still won't be able to afford insurance, or would decline to acquire it? At a recent debate, the Illinois Senator drove the point home, asking Mrs. Clinton, "You can mandate it but there will still be people who can't afford it. And if they can't afford it, what are you going to fine them? Are you going to garnish their wages?" And in an interview with ABC's George Stephanopoulos on Sunday, Mrs. Clinton conceded that "we will have an enforcement mechanism" that might include "you know, going after people's wages."

Well, well. In other words, HillaryCare II isn't all about "choice," but would require financial penalties for people to pay attention, including garnishing wages. To put it more accurately, the individual mandate is really a government mandate that requires brute force plus huge subsidies to get anywhere near its goal of universal coverage.

Mitt Romney's mandate program in Massachusetts is already expected to reach $1.35 billion in annual costs by 2011, up from $158 million today. And that's with only half of the previously uninsured currently enrolled; no less than 20% didn't qualify for subsidies and were granted exemptions because the costs were too much of a hardship.

Most experts calculate that a national mandate with subsidies like Mrs. Clinton's would enroll about half to two-thirds of the uninsured, less for a voluntary plan and subsidies alone. But such guesswork is pointless without the basic enforcement assumptions, which Mrs. Clinton refuses to provide. She's more interested in wielding what she calls "a core Democratic principle" against Mr. Obama. "My opponent will not commit to universal health care," she said Saturday.

The logic of Mr. Obama's approach is that policy makers should target those who are priced out of coverage. The Census Bureau says 38% of the uninsured earned more than $50,000 in 2006, 19% above $75,000. They aren't a major public policy problem -- except that a big reason they lack coverage is because it is more expensive than it needs to be thanks to government market interference. And 29% earn under $25,000, which means they probably qualify for existing subsidy programs like Medicaid or Schip but haven't enrolled.

The news here is that all of this is being exposed now, and by a fellow Democrat. Many Americans are uncomfortable with the coercion of the mandate -- and not all of them are Republicans. The California health-care overhaul was recently done in by liberals concerned about its consequences for the working poor.

The political lesson that Mrs. Clinton learned in 1994 wasn't about compromise or market forces. It was that a government health-care takeover can only be achieved gradually and by stealth. Her individual mandate is an attempt to force everyone to buy into a highly regulated and price-controlled system where government redistributes income and dictates coverage. We assume the McCain campaign is paying attention.

On March 4, voters in the Texas Democratic primary will choose between Hillary Clinton and Barack Obama. The battle is shaping up to be a health-care Alamo. Twenty five percent of people living in the Lone Star state are uninsured, according to the U.S. Census. That's the highest rate of any state.

Sen. Clinton has issued the challenge, telling Sen. Obama "I'll see you in Texas." She promises to provide health coverage for "every single one of the nation's 47 million uninsured," and she accuses Sen. Obama of offering a "band aid" solution that would leave about a third of those 47 million uncovered.

In preparation for the Texas showdown, Sen. Clinton and Sen. Obama will debate this Thursday night in Austin -- and both candidates have called for less oratory and more specifics. With that in mind, here are some of the questions they should be asked:

- Sen. Clinton: When you pledge to cover every one of the 47 million uninsured, do you include recent and future newcomers to the United States, legal and illegal?

The recent rise in the uninsured is due primarily to new arrivals and their U.S.-born children, and it is happening mostly in the five border states, according to the Center for Immigration Studies and U.S. Census data. In Texas, the cost of caring for these newcomers and children has been paid by local and state taxes, with little help from the federal government. For example, 39% of babies born in Parkland Hospital in Dallas are children of illegal immigrants. County taxpayers foot the bill.

At the University of Texas Medical Branch at Galveston, doctors are thrust into an ethical crisis. The hospital provides charity care to all. Its budget is at breaking point, and the hospital has had to lay off workers. In December, the hospital proposed that doctors triage cancer patients based on immigration status rather than medical need. But Galveston doctors say they are bound by their oath to heal, and that border control is Washington, D.C.'s problem.

Texas, as a border state, has specific problems, but also some typical ones. Of the nine million children in the U.S. considered "uninsured," six million are already eligible for government programs such as Medicaid or Schip, but their parents have not signed them up.

- Sen. Obama: You have said that you will require all parents to have health insurance for their children. What will you do to enforce this law?

In Texas, 850,000 children are eligible but not enrolled. The available programs provide check-ups, prescription drugs, hospital care, and dental care. The state runs radio ads, hands out brochures in several languages, and partners with community organizations to inform parents about these programs, but parents still fail to act.

- Sen. Clinton: a question about young adults. They think of themselves as invincible and are not apt to buy insurance. Your "mandate" would force them to do so, and more than that, to pay the same premium as middle aged people whose health care needs generally are much greater. You defend the one-price rule as "shared responsibility," but isn't it an unjust, hidden tax on the younger generation?

Today in Austin, Texas a 25-year-old man can buy a $1,000 deductible policy for $70, according to e-healthinsurance.com. A 55-year-old man pays $270 for the same policy. In nearly all states, young adults currently get price breaks, and for good reason. They need, on average, about $1,500 a year in health care. Your health plan bars insurers from giving these price breaks to the young.

- Sen. Obama: You have pledged to make health insurance "affordable." Texas lawmakers have made insurance less affordable by requiring that every plan include in vitro fertilization, acupuncture, marriage counseling and some 50 other features. This is like passing a law saying that the only car you're permitted to buy is a fully loaded luxury sedan.

Would you allow Texans (and all of us who live in states with similarly costly insurance requirements) to shop for cheaper insurance outside our own state?

- Sen. Clinton: You promise that "everyone who is already insured will be able to keep the coverage they have today." Yet your proposal says all health plans must cover services "experts deem necessary."

About 4.5 million people have high-deductible insurance, because it costs less and allows them to make their own decisions about where and when to get medical care. But when Massachusetts passed mandatory health insurance, people with high-deductible plans were forced to switch to more expensive medical policies to meet that state's definition of insurance.

Will that also happen under your proposal?

- Sens. Obama and Clinton: Some doctors and hospitals are worried about your plans to make electronic record-keeping compulsory. What will be the penalty for a doctor who doesn't get computerized?

In the California primary debate, Sen. Clinton claimed a Rand study shows that savings due to information technology could pay for half of her $110-billion-a-year universal health coverage plan. What the Rand study actually says is that information technology will produce savings, estimated at $77 billion a year, but not until year 15 -- and not necessarily for the thousands of doctors and hospitals who are forced to spend $125 billion (Rand's estimate) up front for the equipment.

- Sens. Obama and Clinton: Both your proposals call for limits on the profit margins of insurance companies. Attacking the most unpopular industry in America may sound politically attractive, but if profit margins are legally capped, investors will flee to other industries and private insurance could become a thing of the past. That would leave only a government-run health-care system.

Do you believe the nation should take that risk?

Ms. McCaughey, a former lieutenant governor of New York, is an adjunct senior fellow at the Hudson Institute.

***- Sens. Obama and Clinton: Some doctors and hospitals are worried about your plans to make electronic record-keeping compulsory. What will be the penalty for a doctor who doesn't get computerized?

In the California primary debate, Sen. Clinton claimed a Rand study shows that savings due to information technology could pay for half of her $110-billion-a-year universal health coverage plan. What the Rand study actually says is that information technology will produce savings, estimated at $77 billion a year, but not until year 15 -- and not necessarily for the thousands of doctors and hospitals who are forced to spend $125 billion (Rand's estimate) up front for the equipment.***

I can tell you now that the cost of going electronic is a lot for many physicians including myself. It is not even feasable.Additionally, I have yet to see anywhere wherein it produces any savings, cost efficiencies, extra income, or much of any other benefit to providers who will soon be forced to do it.

It is obviously too much to ask before an election why we can't just stop illegals from coming here and having babies at the expense of citizens. It ain't just in Texas. I see it all the time here in Jersey. I would not be surprised to find out that a large percentage of the 47 million number we hear about is simply this. That said I have people born here who can't afford care because of pre-existing conditions, or they earn too little. Yet instead of helping them we have people waltzing into the country and getting free hospital care.

LONDON — Created 60 years ago as a cornerstone of the British welfare state, the National Health Service is devoted to the principle of free medical care for everyone. But recently it has been wrestling with a problem its founders never anticipated: how to handle patients with complex illnesses who want to pay for parts of their treatment while receiving the rest free from the health service.

Although the government is reluctant to discuss the issue, hopscotching back and forth between private and public care has long been standard here for those who can afford it. But a few recent cases have exposed fundamental contradictions between policy and practice in the system, and tested its founding philosophy to its very limits.

One such case was Debbie Hirst’s. Her breast cancer had metastasized, and the health service would not provide her with Avastin, a drug that is widely used in the United States and Europe to keep such cancers at bay. So, with her oncologist’s support, she decided last year to try to pay the $120,000 cost herself, while continuing with the rest of her publicly financed treatment.

By December, she had raised $20,000 and was preparing to sell her house to raise more. But then the government, which had tacitly allowed such arrangements before, put its foot down. Mrs. Hirst heard the news from her doctor.

“He looked at me and said: ‘I’m so sorry, Debbie. I’ve had my wrists slapped from the people upstairs, and I can no longer offer you that service,’ ” Mrs. Hirst said in an interview.

“I said, ‘Where does that leave me?’ He said, ‘If you pay for Avastin, you’ll have to pay for everything’ ” — in other words, for all her cancer treatment, far more than she could afford.

Officials said that allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.

Patients “cannot, in one episode of treatment, be treated on the N.H.S. and then allowed, as part of the same episode and the same treatment, to pay money for more drugs,” the health secretary, Alan Johnson, told Parliament.

“That way lies the end of the founding principles of the N.H.S.,” Mr. Johnson said.

But Mrs. Hirst, 57, whose cancer was diagnosed in 1999, went to the news media, and so did other patients in similar situations. And it became clear that theirs were not isolated cases.

In fact, patients, doctors and officials across the health care system widely acknowledge that patients suffering from every imaginable complaint regularly pay for some parts of their treatment while receiving the rest free.

“Of course it’s going on in the N.H.S. all the time, but a lot of it is hidden — it’s not explicit,” said Dr. Paul Charlson, a general practitioner in Yorkshire and a member of Doctors for Reform, a group that is highly critical of the health service. Last year, he was a co-author of a paper laying out examples of how patients with the initiative and the money dip in and out of the system, in effect buying upgrades to their basic free medical care.

“People swap from public to private sector all the time, and they’re topping up for virtually everything,” Dr. Charlson said in an interview. For instance, he said, a patient put on a five-month waiting list to see an orthopedic surgeon may pay $250 for a private consultation, and then switch back to the health service for the actual operation from the same doctor.

“Or they’ll buy an M.R.I. scan because the wait is so long, and then take the results back to the N.H.S.,” Dr. Charlson said.

In his paper, he also wrote about a 46-year-old woman with breast cancer who paid $250 for a second opinion when the health service refused to provide her with one; an elderly man who spent thousands of dollars on a new hearing aid instead of enduring a yearlong wait on the health service; and a 29-year-old woman who, with her doctor’s blessing, bought a three-month supply of Tarceva, a drug to treat pancreatic cancer, for more than $6,000 on the Internet because she could not get it through the N.H.S.

Asked why these were different from cases like Mrs. Hirst’s, a spokeswoman for the health service said no officials were available to comment.

In any case, the rules about private co-payments, as they are called, in cancer care are contradictory and hard to understand, said Nigel Edwards, the director of policy for the N.H.S. Confederation, which represents hospitals and other health care providers. “I’ve had conflicting advice from different lawyers,” he said, “but it does seem like a violation of natural justice to say that either you don’t get the drug you want, or you have to pay for all your treatment.”

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Karol Sikora, a professor of cancer medicine at the Imperial College School of Medicine and one of Dr. Charlson’s co-authors, said that co-payments were particularly prevalent in cancer care. Armed with information from the Internet and patients’ networks, cancer patients are increasingly likely to demand, and pay for, cutting-edge drugs that the health service considers too expensive to be cost-effective.

“You have a population that is informed and consumerist about how it behaves about health care information, and an N.H.S. that can no longer afford to pay for everything for everybody,” he said.

Professor Sikora said oncologists were adept at circumventing the system by, for example, referring patients to other doctors who can provide the private medication separately. As wrenching as it can be to administer more sophisticated drugs to some patients than to others, he said, “if you’re a doctor working in the system, you should let your patients have the treatment they want, if they can afford to pay for it.”

In any case, he said, the health service is riddled with inequities. Some drugs are available in some parts of the country but not in others. Waiting lists for treatment vary wildly from place to place. Some regions spend $280 per capita on cancer care, Professor Sikora said, while others spend just $90.

In Mrs. Hirst’s case, the confusion was compounded by the fact that three other patients at her hospital were already doing what she had been forbidden to do — buying extra drugs to supplement their cancer care. The arrangements had “evolved without anyone questioning whether it was right or wrong,” said Laura Mason, a hospital spokeswoman. Because their treatment began before the Health Department explicitly condemned the practice, they have been allowed to continue.

The rules are confusing. “It’s quite a fine line,” Ms. Mason said. “You can’t have a course of N.H.S. and private treatment at the same time on the same appointment — for instance, if a particular drug has to be administered alongside another drug which is N.H.S.-funded.” But, she said, the health service rules seem to allow patients to receive the drugs during separate hospital visits — the N.H.S. drugs during an N.H.S. appointment, the extra drugs during a private appointment.

One of Mrs. Hirst’s troubles came, it seems, because the Avastin she proposed to pay for would have had to be administered at the same time as the drug Taxol, which she was receiving free on the health service. Because of that, she could not schedule separate appointments.

But in a final irony, Mrs. Hirst was told early this month that her cancer had spread and that her condition had deteriorated so much that she could have the Avastin after all — paid for by the health service. In other words, a system that forbade her to buy the medicine earlier was now saying that she was so sick she could have it at public expense.

Mrs. Hirst is pleased, but up to a point. Avastin is not a cure, but a way to extend her life, perhaps only by several months, and she has missed valuable time. “It may be too bloody late,” she said.

“I’m a person who left school at 15 and I’ve worked all my life and I’ve paid into the system, and I’m not going to live long enough to get my old-age pension from this government,” she added.

She also knows that the drug can have grave side effects. “I have campaigned for this drug, and if it goes wrong and kills me, c’est la vie,” she said. But, she said, speaking of the government, “If the drug doesn’t have a fair chance because the cancer has advanced so much, then they should be raked over the coals for it.”

Laughing gas can be useful during complicated dental procedures, but should every health plan be required to cover it and should health insurance cost more because of it?

Barack Obama thinks so. As a state senator in Illinois, he voted to require that dental anesthesia be covered by every health plan for difficult medical cases. Today, the requirement is one of 43 mandates imposed by Illinois on health insurance, according to the Illinois Division of Insurance. Other mandates require coverage of infertility treatments, drug rehab, "personal injuries" incurred while intoxicated, and other forms of care.

By my count, during Mr. Obama's tenure in the state Senate, 18 different laws came up for a vote and passed that imposed new mandates on private health insurance. Mr. Obama voted for all of them.

As a presidential candidate, Mr. Obama says people lack health insurance because "they can't afford it." He's right. But he is also partly responsible for why health insurance is too expensive. A long list of studies show that mandates like the ones Mr. Obama has championed drive up the cost of insurance for the very people priced out of coverage.

A 2008 study by an insurance-industry supported research organization, the Council for Affordable Health Insurance (CAHI), estimates that mandates increase the cost of basic health coverage by 20% to 50%, depending on the state. Average policies in high-mandate New Jersey cost about $4,000 according to a 2004 insurance survey, much more than the $1,200 charged in low-mandate Wyoming.

CAHI estimates that there are 1,961 state-mandated benefits across the country. It's not just specific products and services that get mandated, but also whole categories of providers like chiropractors and psychologists. By one count, states have enacted about 500 laws mandating coverage for 25 different types of providers.

States also mandate new categories of eligibility that force small businesses to cover additional dependents. One popular measure is the "slacker mandate," which extends coverage to unmarried dependents under the age of 30.

Not all mandates are equally expensive. Drug rehab, for example, increases a plan's premiums by 9% on average, according to America's Health Insurance Plans (AHIP). Coverage for psychologists adds 12% to premiums. But in total, in some states mandates increase the cost of insurance from 10% to 20%, according to AHIP.

These increased costs aren't shared equally among all who have health insurance. People who are covered through self-insured employers (usually large corporations) are shielded from state mandates because of the federal Employee Retirement Income Security Act (ERISA), which prevents states from enacting controls on plans that cross state lines.

The burden of paying for state mandates is usually borne by individuals who buy their own insurance, small employers and others not covered by ERISA. In total, about half of the people who have insurance bear the brunt of the cost of state mandates. And, as it turns out, individuals who do not work for large corporations are much more likely to be uninsured. AHIP calculates that between 20%-25% of uninsured Americans can't afford coverage because of the increased cost of providing mandated care.

It doesn't have to be that way. If insurers were allowed to offer "bare-bones" plans – which would be cheaper because they would cover just essential care – many consumers who are priced out of health insurance now would likely buy these plans instead of living without insurance.

State mandates even hurt those who have insurance because they prompt insurers to cut back on coverage for catastrophic illnesses. This undermines the purpose of insurance by turning policies into prepaid health care rather than security from the economic consequences of serious medical problems. And because many mandates define the duration and scope of specific benefits, they lock in treatment standards that grow outdated as knowledge advances. That can diminish incentives to find more effective ways of delivering medical care.

Why, then, do we have mandates?

For the simple reason that each mandate has a powerful constituency – be it chiropractors, dentists or other groups – who benefit when their services are included on the list of mandated care. These groups pressure lawmakers to expand the list of mandates and, over time, the list grows to be very long and expensive. Often the care that is being mandated is for minor medical problems because small, routine ailments are suffered by more people and therefore have broader political constituencies.

One way to make insurance more affordable is to extend the benefits of the ERISA exemption to people who buy insurance on their own, putting them on a level playing field with those who get coverage through large employers by freeing them from expensive state insurance laws.

Most insurance plans would still cover important health-care items such as prenatal HIV testing or routine colon cancer screening or bone density tests – three additional mandates Mr. Obama helped enact in Illinois. But without government mandates, plans would also have the flexibility to offer lower-priced insurance options.

Better still, Congress could pass legislation that has long languished in the House allowing people to purchase health plans across state lines. People could choose which state regulations to buy into, creating a market for the insurance mandates. This would give states more incentives to fix local problems that have helped make health insurance expensive in the first place. It's a fair bet that there would be an exodus of policyholders from higher-cost, higher-mandate states like New Jersey and even Illinois (which has more expensive mandates than about half of the other states).

Mr. Obama says people need more options to purchase insurance outside the workplace. He also says he can draw on his experience as a state legislator to lead a reform of the kinds of special interests that pursue these mandated benefits. Right now Mr. Obama's health-care proposal, like Hillary Clinton's plan, does the opposite by adding federal regulations on top of state laws.

"My plan emphasizes lowering costs," Mr. Obama says. If that is really what he wants to do, he can start by freeing consumers from forced subsidization of the pricey state mandates. Given a choice between the lower costs he promises and subsidized dental anesthesia he has delivered, some would opt for the affordable health insurance and make do with some extra Novocain.

Dr. Gottlieb is a resident fellow at the American Enterprise Institute.

Medicaid Money LaunderingMay 19, 2008; Page A14Every politician moans that entitlement spending is out of control, so it ought to be easy at least to stop blatant fraud and abuse. Evidently not: Congress is currently resisting an attempt to rein in even a Big Con that everyone acknowledges.

The scene of this crime is Medicaid, the open-ended program that provides health coverage for about 59 million low-income people, with the rolls expanding every year. States determine eligibility and what services to cover, and the feds pick up at least half the tab, though the effective "matching rate" is as high as 83%. Now it turns out that states have been goosing their financing arrangements to maximize their federal payouts and dump more of their costs onto taxpayers nationwide.

The swindle works like this: A state overpays state-run health-care providers, such as county hospitals or nursing homes, for Medicaid benefits far in excess of its typical rates. Then the federal government reimburses the state for "half" of the inflated bills. Once the state bags the extra matching funds, the hospital is required to rebate the extra money it received at the scam's outset. Cash thus makes a round trip from states to providers and back to the states – all to dupe Washington.

The Government Accountability Office and other federal inspectors have copiously documented these "creative financing schemes" going back to the Clinton Administration. New York deposited its proceeds in a Medicaid account, recycling federal dollars to decrease its overall contribution. So did Michigan. States like Wisconsin and Pennsylvania fattened their political priorities. Oregon funded K-12 education during a budget shortfall.

The right word for this is fraud. A corporation caught in this kind of self-dealing – faking payments to extract billions, then laundering the money – would be indicted. In fact, a new industry of contingency-fee consultants has sprung up to help states find and exploit the "ambiguities" in Medicaid's regulatory wasteland. All the feds can do is notice loopholes when they get too expensive and close them, whereupon the cycle starts over.

The Bush Administration did just that. In 2003, it began audits that resulted in 29 states dialing back the practice. In 2007, officials tried to make the reforms permanent through formal rules changes, saying federal Medicaid dollars would only pay for Medicaid services received by Medicaid beneficiaries.

Naturally, the states were furious. All 50 Governors were (and are) opposed, while pressure groups like AARP and their media collaborators chime in with horror stories about "cuts" to the social safety net. Congress promptly forbade enforcement of the new regulations. That moratorium, which was slipped into last year's Iraq war funding bill, expires at the end of this month.

Now Congress wants to extend it until President Bush leaves office. The House passed a bill – 349-62 – but Harry Reid was unable to whisk it through the Senate unnoticed. Wavering GOP Senators are trying to strike a deal with the Bush Administration, which is threatening a veto, mostly with offers to beef up the $25 million allocated to "combat" Medicaid fraud and abuse. Of course, these antifraud troops only fight after state schemes have paid out. And should the moratorium stick around, states will merely revert to their con artistry, knowing they are no longer being watched.

A reform alternative would be for the government to distribute block grants, rather than a set fee for every Medicaid service. That would amputate Washington from state accounting and insulate taxpayers from these shakedowns. States would have an incentive to spend more responsibly, and also craft innovative policies without Beltway micromanagement. But we can dream.

In the short term, Congress could – but probably won't – allow the Administration to close this case. No one really knows how much the state grifters have already grabbed, though the Congressional Budget Office estimates that the Administration remedies would save $17.8 billion over five years and $42.2 billion over 10.

We realize this is considered a mere gratuity in Washington, but Medicaid's money laundering is further evidence that Congress isn't serious about spending discipline.

The New Big DigMay 21, 2008Mitt Romney's presidential run is history, but it looks as if the taxpayers of Massachusetts will be paying for it for years to come. The former Governor had hoped to ride his grand state "universal" health-care reform of 2006 to the White House, but his state's residents are now having to live with what he and the state's Democratic Legislature passed. As the Boston press likes to say, it's "the new Big Dig."

The showpiece of RomneyCare was its individual mandate, a requirement that all Massachusetts residents obtain health insurance by July of last year or else pay penalties. The idea was that getting everyone into the insurance system would eliminate the "free-rider" problem of those who refuse to buy insurance but then go to emergency rooms when they're sick; thus costs would fall. "Will it work? I'm optimistic, but time will tell," Mr. Romney wrote in these pages in 2006.

Well, the returns are rolling in, and the critics look prescient. First, the plan isn't "universal" at all: About 350,000 more people are now insured in Massachusetts since the reform passed. Federal estimates put the prior number of uninsured at more than 657,000, so there was a reduction. But it was not secured through the market reforms that Governor Romney promised. Instead, Massachusetts also created a new state entitlement that is already trembling on the verge of bankruptcy inside of a year.

Some two-thirds of the growth in coverage owes to a low- or no-cost public insurance option. Called Commonwealth Care, it uses a sliding income scale to subsidize coverage for everyone under 300% of the federal poverty level, or about $63,000 for a family of four. Commonwealth Care also accounts for 60% of statewide growth in individual insurance over the last year, and the trend is expected to accelerate, perhaps double.

One lesson here is that while pledging "universal" coverage is easy, the harder problem is paying for it. This year's appropriation for Commonwealth Care was $472 million, but officials have asked for an add-on that will bring it to $625 million. For 2009, Governor Deval Patrick requested $869 million but has already conceded that even that huge figure is too low. Over the coming decade, the expected overruns float in as much as $4 billion over budget. It's too early to tell how much is new coverage or if state programs are displacing private insurance.

The "new Big Dig" moniker refers to the legendary cost overruns when Boston rebuilt its traffic system. Now state legislators are pushing new schemes to offset RomneyCare's runaway expenses, including reductions in state payments to doctors and hospitals, enlarged business penalties, an increase in the state tobacco tax, and more restrictions on drug companies and insurers.

Mr. Romney's fundamental mistake was focusing on making health insurance "universal" without first reforming the private insurance market. The "connector" that was supposed to link individuals to private insurance options has barely been used, as lower-income workers flood to the public option. Meanwhile, low-cost private insurers continue to avoid the state because it imposes multiple and costly mandates on all policies.

Hailed at first as a new national model, the Massachusetts nonmiracle ought to be a warning to Washington. Barack Obama and Hillary Clinton are both proposing versions of RomneyCare on a national scale, with similar promises that covering everyone under a government plan will reduce costs. Mr. Obama at least argues that more people would be covered were insurance more affordable. But his solution is Massachusetts on steroids – make insurance less expensive for policyholders by transferring the extra costs onto the government. Mrs. Clinton likes that but also wants the individual mandate, despite the mediocre results so far.

The real problem in health care is the way the tax code and third-party payment system distort incentives. That's where John McCain has been focusing his reform efforts – because that really does have the potential to reduce costs while covering more of the uninsured – and Republicans ought to follow his lead.

In this respect paradoxically, we can be thankful that Massachusetts ignored the cost problems that doomed other recent liberal health insurance overhauls in California, Pennsylvania, Wisconsin and Illinois. The Bay State is showing everyone how not to reform health care.

See all of today's editorials and op-eds, plus video commentary, on Opinion Journal.

The Florida Revelation . . .May 29, 2008; Page A16Republicans in Congress may be out of gas, but that doesn't mean conservative ideas aren't percolating elsewhere, and even on the supposedly Democratic stronghold of health care. Take the news from Florida, where GOP Governor Charlie Crist succeeded last week in moving an innovative reform through the state legislature.

The Sunshine State has about 3.8 million people without insurance, or about 21% of the population, the fourth-highest rate in the country. The "Cover Florida" plan hopes to improve those numbers by offering access to more affordable policies. As even Barack Obama says, the main reason people are uninsured isn't because they don't want to be; it's because coverage is too expensive.

But the Florida reform, which both houses of the legislature approved unanimously, renounces Mr. Obama's favored remedy: It nudges the government out of the health-care marketplace. Insurance companies will be permitted to sell stripped-down, no-frills policies exempted from the more than 50 mandates that Florida otherwise imposes, including for acupuncture and chiropractics. The new plans will be designed to cost as little as $150 a month, or less.

Mr. Crist observed that state regulations increase the cost of health coverage, and thus rightly decided to do away with at least some of them. It's hard to believe, but this qualifies as a revelation in the policy world of health insurance. The new benefit packages will be introduced sometime next year and include minimum coverage for primary care and catastrophic expenses for major illness.

Critics are already saying that, without mandates, the plan won't guarantee quality of care. That's purportedly why the states have imposed more than 1,900 specific-coverage obligations. But invariably mandates are the product of special-interest lobbying. Health-care providers – not consumers – are always asking for tighter regulation, because they profit from making everyone subsidize generous plans that cover, say, podiatry or infertility treatment. Given the choice, consumers might choose policies that cover some services but not others.

These government rules are imposed without regard for how much they will cost and who will bear the burden. In practice, the costs are disproportionately carried by lower- and middle-income workers, who already on average have more limited insurance coverage as part of their compensation, or none at all. When prices rise because of mandates, the less affluent are often forced to make an all-or-nothing choice between "Cadillac coverage," which involves just about everything, or going uninsured. In other words, they're prohibited from buying the lower-cost options that might be better suited to their needs.

Governor Crist is to be credited for removing this artificial, regressive floor on plans. It's a simple matter of equity. And though the plan will only enroll those who have gone without coverage for six months, it also creates a clearinghouse that will let small businesses that can't afford coverage offer their employees a variety of similar policies.

Despite his often populist brand of politics (such as on hurricane insurance), Mr. Crist also avoided the typical liberal health-care response of expanding public programs. Mitt Romney should have taken this route in Massachusetts, but fell instead for the siren song of "universal coverage," even if provided by the government. Florida is already having a tough fiscal year, but such state-level expansions are often pushed anyway.

Some 13 states currently offer bare-bones policies on a full or trial-run basis. While not a cure-all, they're movement in the right direction – especially as the states can't do anything about the continuing tax bias for employer-provided health insurance. That kind of much-needed change can only come from Washington, as John McCain is proposing.

The Florida success also shows the political benefits when Republicans talk seriously about health care. Mr. Crist has made increasing consumer choice a signature issue. When Mr. McCain talked up his health-care reforms earlier this spring, he did so in Tampa. He chose the right state.

I have mixed feelings about *universal* health care. Of course the idea of world class health care for everyone that is paid for by x is a wonderful thought. Who isn't for that? But we all know it isn't that simple.

As one who pays for health care for myself and an employee I have many different thoughts and conerns from different directions but I don't have the answers. The only thing I can say is that for any universal coverage to not bankrupt the system there would *have* to be some form of rationing. Most Americans don't understand this and on an individual basis refuse to except this. And as a doctor I don't want to be the one in the middle who is the person who tells the patient they cannot have that MRI on day #1 for a shoulder or back sprain. Yet the business guys with the HMOs have put us in that spot. There better be strict guidelines set up in a way so I can refer this to the patient. "No, you can't have this test because you don't qualify by national guidelines until these steps are followed".

Everyone cannot scour the country like Ed Kennedy shopping for all sorts of experimental care and expect others to pay for it.BTW I wonder about his care. Why is it he couldn't get the care in Massachussetts where there is world class health care? Ever here of Mass General? What is that guy at Duke and their University trying to sell? There is to me an *obvious* self promotional aspect to their offering experimental stuff to a famous wealthy guy. It is a sales decision - no more and no less.

Anyway here is some thoughts on universal care:

***Senators Clinton’s and Obama’s split over mandating coverage distinguishes them from one another, but does that difference matter?

In the seemingly endless Democratic primary, Sens. Hillary Clinton and Barack Obama have expended a lot of effort trying to distinguish themselves from one other. She stands for experience, he stands for change, and so on.

They both stand for health care reform and have acknowledged that they propose very similar plans for covering the uninsured. But their plans do have one difference—mandates for coverage—and there doesn’t seem to be any consensus on whether that is a big, important difference or a small, insignificant one.

Both plans require insurers to offer coverage to everyone, and use federal funds to make the coverage affordable for consumers. However, Mrs. Clinton’s plan will require all Americans to purchase coverage or face as-yet-unspecified penalties. Mr. Obama’s plan requires mandatory insurance only for children; for adults, coverage will be optional.

Proxies explained their candidates’ proposals at the 2008 World Health Care Congress (WHCC) in Washington, D.C., where one of the keynote addresses featured representatives of the three major presidential campaigns. Since my last column focused on Mr. McCain’s proposals, I’ll stick to the discussion between Mrs. Clinton’s and Mr. Obama’s campaigns.

Democrats’ health plans not much help to undecided votersU.S. Representative Jim Cooper of Tennessee, who represented Mr. Obama, said the mandate issue has been overplayed. “I think that’s much ado about a technical subject,” he told the audience of health care leaders in April. “The health care plans of Hillary Clinton and Barack Obama are almost identical. We are for universal coverage.”

That’s not true, argued Chris Jennings, the political strategist who represented Mrs. Clinton at the WHCC. “There already is [bipartisan support],” he said. He noted that mandatory coverage legislation has been proposed by Sen. Ron Wyden (D-OR) and Sen. Robert Bennett (R-UT), and two Republican governors, Mitt Romney and Arnold Schwarzenegger, have been the driving forces behind state efforts to mandate insurance.

“The reason why we want everyone to be in the system is to make it work rationally,” Mr. Jennings said. If consumers can wait until they are sick to purchase health insurance, it would raise the premiums of those who buy insurance as well as drawing intense protest from health insurers, he explained.

Obviously, the most likely to opt out under the non-mandatory plan would be the young and healthy whose premiums would typically subsidize the cost of covering the less healthy, more expensive patients. Mr. Obama’s advocates argue that if health insurance is made affordable, almost everyone would choose to buy it, but there’s no way to prove that without enacting a plan.

The Obama plan does have the advantage of being less expensive. Analysts have calculated that his plan would cost taxpayers 50%-80% of what the Clinton plan would. Since either plan would cost the government tens of billions of dollars a year, it’s somewhat difficult for laypeople to really grasp the price difference.

So what is the priority in creating a new health care coverage system? Gaining bipartisan support? Ensuring that everyone is within the system? Limiting cost?

Attendees at the WHCC, who were mostly health care industry executives, seemed to be thoroughly divided about the answers to these questions. After the representatives from the two Democratic campaigns and a spokesperson for Mr. McCain had presented their candidates’ proposals for health reform, the audience voted on their perceptions of feasibility and cost.

The votes were just about even. Mrs. Clinton’s plan got slightly positive ratings, with about 54% of the group finding it feasible and 51% saying it would help with costs. The voters were exactly split on the feasibility of Mr. Obama’s plan and slightly favorable (54%) on cost. The evaluation of Mr. McCain’s plan was slightly negative, with 45% voting yes on feasibility and 46% on cost.

With that mixed evaluation from the health care experts, it’s no wonder that the American voters are still undecided about who they want to lead health care reform.***

One might think because I am a doctor I would have some strong opinions one way or the other regarding what is *best* for health care, but I don't. I'm just trying to pay my bills like everyone else. I don't endorse McCain or the others based on their health care opinions except to the extent that I don't want even more regulation, strangulation, and an even more gigantic government in any shape or form.

Despite the importance of health care in the 2008 presidential campaign, relatively little attention has been paid to the plans that the Republican nominee Sen. John McCain has proposed for the U.S. health care system.

Part of that is because Sen. McCain himself has spent less time talking about the issue than his Democratic opponents. His reticence makes sense, given that Republican voters rank health care as a less important issue (fourth) than do Democrats (second), a Kaiser Foundation poll found. But Sen. McCain has released some proposals to reform health care, and although his plans are not fully fleshed out, they represent a dramatic change from both the current status quo and Democratic proposals.

Unlike the Democrats, cost, rather than access, is the focus. “The problem is not that most Americans lack adequate health insurance,” Sen. McCain told an audience in Des Moines, Iowa. “The biggest problem with the American health care system is that it costs too much.”

John McCain touts his plan for the U.S. health care systemThe centerpiece of his plan to tackle cost is to change the tax code, which would eliminate the incentives for employer-sponsored health coverage and offer individuals a $2,500 tax credit ($5,000 per family) for purchasing their own insurance. Under his plan, which also encourages health savings accounts and cost transparency, patients will have substantially more responsibility for making their own health care and coverage determinations, and would be less likely to choose the most expensive and often unnecessary options, he said in the same speech.

Although states would lose some control over insurance regulation and medical licensing, they would take on the new responsibility of finding coverage for high-risk, high-cost patients. States should develop methods for providing additional assistance to families who face unusually high premiums, Sen. McCain said. “The federal government can help fund this effort, but in exchange states should allow Medicaid and SCHIP funds to be used for private insurance,” he explained.

Sen. McCain envisions substantial changes to private insurance as a result of his encouragement of competition. “Insurance should be innovative, moving from job to home, job to job, and providing multi-year coverage. Allow individuals to get insurance through any organization or association that they choose,” his Web site states.

Of concern to internists, he favors eliminating lawsuits against physicians who follow clinical guidelines and adhere to protocols, payments for coordinated care and nonpayment for preventable errors.

Although he hasn’t provided details, Sen. McCain has also expressed opinions on some other hot-button health care issues. He supports walk-in clinics as an alternative/addition to physician offices and emergency rooms. He opposed Medicare Part D because of the cost of providing drug benefits to senior citizens who could afford to pay for their medications, but he favors re-importation of drugs and faster introduction of generics to lower drug expenditures.

Some responsibility for lowering the expense of the U.S. health care system also will fall onto the general public under the McCain plan. He mentions obesity, diabetes and high blood pressure specifically as areas where individual efforts could reduce disease incidence.

A discussion of autism recently caused some controversy for Sen. McCain. According to the New York Times, he recently told a Texas audience that “strong evidence” indicates that vaccine preservatives are causing rising autism rates. His comment drew heat from host of experts who cited strong evidence to the contrary.

Sen. McCain is the underdog in convincing voters to support his plan for reform. A March Wall Street Journal poll conducted by Harris Interactive after the Ohio and Texas primaries found that 45% of voters would trust Democrats to lead health reform while only 25% said they would trust Republicans. Among the three remaining candidates, 44% of those polled said they would trust Sen. Hillary Clinton with overhauling health care, compared with 40% for Sen. Barack Obama and 30% for Sen. McCain.

Presumably, as the campaign moves forward, Sen. McCain will release more details. For information on his opponents’ plans, check back next month, when the Campaign Trail will conduct a similar analysis of the Democratic candidates’ health care platforms.

There is a reason patients are not paid a lot of money to participate in pharmaceutical studies. Ethics experts and institutional review boards composed of religious, business, legal medical and other lay people decide that offering too much money clouds the judgement of people into participate in these studies. In fact I had conducted some of these myself and it would have been *a lot easier* to offer a lot more money and have more participants then we would need rather than be able to offer a pittence and take forever to find subjects. Additionally IRB approve the informed consent, advertising, and to suggest that these veterans or anyone else is just thrown into these studies without their complete and explicit consent is bogus publicity. These are not Nazi experiments. The patient know full well they are in experimental studies and know full well there are risks.

Again as I said before a one in a million reaction to chantix is hardly some sort of scandal. I think Obama dumba should have to spend a month taking care of the millions of patients dying of cancer, and emphysema because they couldn't stop smoking - that SOB.

UPDATE: Obama's office sent a letter Tuesday to James Peake, secretary of the Department of Veterans Affairs, on the issue. You can read the full text of the letter here.

UPDATE II: Sen. John Cornyn, Texas Republican, issued his own letter to Peake as well. You can read it here.

The government is testing drugs with severe side effects like psychosis and suicidal behavior on hundreds of military veterans, using small cash payments to attract patients into medical experiments that often target distressed soldiers returning from Iraq and Afghanistan, a Washington Times/ABC News investigation has found.

In one such experiment involving the controversial anti-smoking drug Chantix, the Department of Veterans Affairs (VA) took three months to alert its patients about severe mental side effects. The warning did not arrive until after one of the veterans taking the drug had suffered a psychotic episode that ended in a near lethal confrontation with police.

ROD LAMKEY JR./THE WASHINGTON TIMES Veteran James Elliott arrives at the Veterans Affairs Medical Center in Washington for his scheduled substance-abuse class in April. Mr. Elliott, a chain smoker, served 15 months in Iraq as an Army sharpshooter and suffers post-traumatic stress disorder.

ROD LAMKEY JR./THE WASHINGTON TIMES Iraq war veteran James Elliott opted for a government clinical trial for a smoking-cessation drug for $30 a month, starting in November. Two weeks later, the FDA informed the VA of serious side effects.

ROD LAMKEY JR./THE WASHINGTON TIMES STILL SMOKING: Iraq war veteran James Elliott smokes on his porch in Silver Spring as he talks about his experiences in war and dealing with post-traumatic stress disorder. Mr. Elliott suffered a psychotic episode while taking the anti-smoking drug Chantix.

James Elliott, a decorated Army sharpshooter who suffers from post-traumatic stress disorder (PTSD) after serving 15 months in Iraq, was confused and psychotic when he was Tasered by police in February as he reached for a concealed handgun when officers responded to a 911 call at his Maryland home.

For photos, video of James Elliott, official FDA documents and more, visit the interactive site for the Disposable Heroes report.

Mr. Elliott, a chain smoker, began taking Chantix last fall as part of a VA experiment that specifically targeted veterans with PTSD, opting to collect $30 a month for enrolling in the clinical trial because he needed cash as he returned to school. He soon began suffering hallucinations and suicidal thoughts, unaware that the new drug he was taking could have caused them.

Just two weeks after Mr. Elliott began taking Chantix in November, the VA learned from the Food and Drug Administration (FDA) that the drug was linked to a large number of hallucinations, suicide attempts and psychotic behavior. But the VA did not alert Mr. Elliott before his own episode in February.

In failing to do so, Mr. Elliott said, the VA treated him like a "disposable hero."

From the New England Journal of Medicine which does carry of leftist flavor when it comes to politics and health care. (Well they do reside in Massachussetts. )

I don't know why Hollywood shouldn't pay for our health care needs with a windfall profits tax. Maybe athletes and sports team owners should pay a windfall tax too (who still weasel public money for their stadiums.). And my well known favorite industry - the music industry.

This is what we will see from Bo on a national scale. It is a very complicated situation so I have no real opinion one way or another and am just sitting helplessly on the sidelines anyway so what ever will be - will be....

****The New England Journal of MedicineVolume 358:2757-2760 June 26, 2008 Number 26

The far-reaching health care reforms that Massachusetts enacted in April 2006 are often cited as a model for other states.1 After 2 years, the good news is that the new programs have ramped up rapidly, the number of people without health insurance has been substantially reduced, and overall public and political support remains broad. Early data suggest that access to care has improved, especially among low-income adults; there have also been "reductions in out-of-pocket health care spending, problems paying medical bills, and medical debt."2 As of May 2008, about 350,000 residents — 5.5% of the state's population — were newly insured (see figure). About half of them are enrolled in Commonwealth Care, a subsidized insurance program for adults who have no access to employer-sponsored insurance, Medicare, Medicaid, or veterans' or student insurance programs and who earn no more than 300% of the federal poverty guidelines. About a third have purchased private insurance or gained employer-sponsored coverage, and the rest have enrolled in Medicaid. About 72% of the approximately 25,000 people with new individual policies have purchased them through Commonwealth Choice, an unsubsidized offering of private health plans approved by the Commonwealth Health Insurance Connector Authority, which administers many aspects of the reforms. In addition, the individual and small-group insurance markets have been merged, markedly reducing the cost of individual premiums.

Figure 1View larger version (34K):[in this window][in a new window]Get Slide Growth in Health Insurance Coverage in Massachusetts after Health Care Reform.

Panel A shows the health insurance coverage among the 352,170 Massachusetts residents (5.5% of the 2007 state population of 6.4 million) who are newly insured. An estimated 550,000 to 715,000 residents (8.6 to 11.2%)1 were without health insurance before reform. Data for Commonwealth Care enrollees are from the Commonwealth Connector as of May 1, 2008. Medicaid data are from MassHealth as of February 29, 2008. Data for private insurance are from the Massachusetts Association of Health Plans, representing the increase in the number of people enrolled in commercial insurance between January 1, 2007, and January 1, 2008. New private-insurance enrollment includes coverage through Commonwealth Choice, an unsubsidized offering of approved private health plans that has been available through the Commonwealth Connector since July 2007; as of May 1, 2008, a total of 18,122 people had purchased insurance through Commonwealth Choice. Panels B and C show the numbers of residents enrolled in Commonwealth Care and Commonwealth Choice, respectively.

Not all the news is good, however. Perhaps 5% of the state's population — the exact figure is a matter of conjecture and may be higher — is still uninsured, the financial burden of the reforms is increasing, and the challenges of sustaining the subsidized program have been exacerbated by the economic downturn. The features of plans that decrease the cost of premiums also increase out-of-pocket costs for those who obtain care. Although adults reported lower levels of health care needs that remained unmet because of cost in the fall of 2007 than in the previous year, those with low incomes reported increased difficulty in getting appointments or in finding a doctor or other provider who would see them.2 And the state ultimately decided that not all residents must actually carry health insurance, as the legislation originally intended: exemptions are available for adults who make too much money to enroll in the subsidized insurance program but are deemed unable to afford policies in the private market; others can be exempted on religious grounds or when unusual financial circumstances arise. If more residents were eligible for subsidized insurance, fewer would qualify for hardship exemptions, but such an approach would further increase the cost of the new programs. Already, enrollment in Commonwealth Care is growing faster than was projected. Annual state spending would be $1.08 billion for fiscal year 2009 if 255,000 residents are enrolled, an increase of about 80,000 enrollees from the current number.3 If 225,000 residents enroll, as an earlier estimate suggested, spending would be $869.4 million. By comparison, spending for Commonwealth Care was $132.9 million in fiscal year 2007 and is projected to be $647.4 million in fiscal year 2008. Moreover, as compared with the national average, the per-capita cost of medical care in Massachusetts is high.

"To maintain public and financial commitment to the new programs, controlling costs is 110% of the challenge for the next several years," according to Jon Kingsdale, executive director of the Commonwealth Connector. The monthly cost per member in the subsidized insurance program is $352.43, which is about what was budgeted and considerably less than the median cost of employer-sponsored coverage in the state. There are no monthly premiums for adults earning less than 150% of the federal poverty guidelines (in 2008, $15,612 for an individual and $31,812 for a family of four); premiums for those who earn 150 to 300% of the federal poverty guidelines are set according to a sliding scale, with a maximum premium for an individual of $105 a month. About 70% of those who have signed up pay no premiums. People who are eligible for Commonwealth Care are deemed to have access to affordable coverage; Medicaid covers the children of adults enrolled in Commonwealth Care.

The requirement to carry insurance is enforced through the state income-tax return. In general, the Massachusetts Department of Revenue uses the affordability schedule adopted by the Commonwealth Connector and other financial and insurance information to verify the self-reported information on tax returns and to determine eligibility for hardship exemptions. In 2008, the maximum penalty for not having insurance is $912. In 2007, it was $219. Revenue from this penalty is expected to be $8.5 million for fiscal year 2008.3

In June 2008, the Department of Revenue released preliminary data about the health insurance information reported on 2007 tax returns, covering 86% of the tax filings that are eventually expected. Of the taxpayers required to file insurance information, only 1.4% failed to comply. About 168,000 of 3.34 million adults (5.0%) reported that they did not have health insurance coverage at the end of the year. On the basis of the affordability schedule, about 97,000 were deemed "able to afford" insurance — 86,000 who paid the penalty and 11,000 who have appealed it. About 62,000 were deemed "unable to afford insurance" and are thus eligible for an exemption. In addition, about 9,000 taxpayers claimed a religious exemption, and about 200 had already obtained a "certificate of exemption," for financial reasons, from the Commonwealth Connector. About 10% of residents either do not file tax returns or are not accounted for as dependents on the returns of others, so the actual number without health insurance is probably higher.

As of January 1, 2009, people with health insurance must have plans that provide "minimum creditable coverage." Among other requirements, such plans must cover at least three doctor visits for an individual or six for a family before charging any deductible, and they must offer prescription-drug coverage (with a limit on any separate deductible of $250 for an individual and $500 for a family). However, annual deductibles (capped at $2,000 for an individual and $4,000 for a family) and out-of-pocket spending (capped at $5,000 for an individual and $10,000 for a family) can be very high.

In 2008, health insurance in Massachusetts is considered affordable — regardless of the premium — for individuals with incomes above $52,501, for couples with incomes above $82,501, and for families of any size with incomes above $110,001, according to the Commonwealth Connector. For people with lower incomes, the affordability schedule, which is revised annually, is used to determine whether residents can pay for health insurance, regardless of whether it is obtained through the Commonwealth Connector or directly from an insurer. According to the 2008 schedule, affordable policies typically require no more than 7.5% to 10.6% of income to be paid for premiums; the percentages vary according to income and type of household. People with preexisting medical conditions are not charged more for individual policies. However, because premiums increase with age, people with incomes below the affordability thresholds are considered to have no affordable private insurance options after a certain age — currently, 55 years for individual coverage, 50 years for couple coverage, and 30 years for family coverage. Income-based categorical exemptions apply mostly to adults who are not offered employer-sponsored insurance. Until a more detailed analysis of tax returns is completed, state officials will not know how many of the people deemed unable to afford health insurance fall into these categories. And, of course, people who use medical care have additional expenses for copayments, deductibles, prescription charges, and other out-of-pocket costs.

Premiums for the unsubsidized Commonwealth Choice program will increase by an average of 5% for fiscal 2009, which begins on July 1. Government payments for premiums in Commonwealth Care will increase by an average of 9.4%. The state's cost for Commonwealth Care is partially offset by federal reimbursement — projected to be at $268.3 million in fiscal year 2008 and for $360.6 million in fiscal year 20093 — and a decrease in payments to community health centers and hospitals that treat the uninsured, which has caused difficulties for some centers and hospitals. Other revenues are limited. Revenue from the "fair share contribution," an annual per-employee charge of $295 paid by businesses that have 11 or more full-time–equivalent employees but do not provide or contribute to health insurance, is projected to be $6.7 million in fiscal 2008, as compared with the $50 million per year that was estimated when the reform was enacted.1,3 The difference could reflect inaccurate or incomplete reporting or an inaccurate initial estimate of the number of employers that would be subject to the assessment. More people, including low-income adults, have employer-sponsored insurance than did before the reform.

Massachusetts has thus far avoided legal challenges to its reforms that might have been brought under the federal Employee Retirement Income Security Act, which prohibits states from setting plan standards for self-insured employers. Possible explanations are that the requirement for maintaining a minimum standard of coverage is placed on individuals rather than employers, that businesses largely support the reform,4 and that their obligations are modest. An employer's requirements are met if at least 25% of its workers enroll in the company health plan or if it offers to pay at least one third of the premium for individual coverage. Employers are not required to provide health insurance to part-time employees. So far, employers have blocked efforts to make them pay more of the costs of the reform.

Health care reform in Massachusetts is not a panacea for the many shortcomings of the health care system.5 It is worth remembering that California, for example, has more people without health insurance (6.7 million) than Massachusetts has residents (6.4 million) and that the financing and delivery of medical care have not changed.1 Having health insurance is not having health care.5 There are still many difficulties with access to primary care and other services. However, Massachusetts has made some strides, and given sufficient resources, more can be done. This includes identifying and reaching people who are still uninsured and helping them gain coverage, expanding employer-sponsored insurance, and improving the options for part-time employees, for low-paid workers who are offered insurance by their employers but who earn less than 300% of the federal poverty guideline and cannot afford it, and for others with hardship exemptions. The state legislature is considering new cost-control measures, and there is interest in a plan from Blue Cross–Blue Shield of Massachusetts, the largest carrier in the state, which pays doctors and hospitals according to a combination of capitation and pay-for-performance approaches. As a practical matter, the improvements in health insurance coverage can continue indefinitely as long as public and political support remain strong and the state is willing — with the substantial help of the federal government through the renewal of a Medicaid waiver agreement — to keep paying the ever-increasing bill.

"Your accomplishment of [universal access] is the envy of every U.S. citizen who understands what you've done," Sen. Edward Kennedy (D., Mass.) told a Canadian audience in 1996. This week, a major international study confirms that Mr. Kennedy is right to stay at home for his own cancer care: U.S. medicine bests the cancer treatment available to people in 30 other countries.

The Concord study compares five-year cancer survival rates for several malignancies: breast cancer in women; prostate cancer; colon and rectal cancer in women and men. Combining the efforts of some 100 researchers, drawing data from almost two million cancer patients in 31 countries, the study, to be published in the August issue of The Lancet, is groundbreaking.

Who's on top? Arguably Cuba, which records the best overall outcomes for breast cancer and colorectal cancer (in women), and seems to beat U.S. health care in three out of the four categories. The study's authors -- who apparently hold higher standards than filmmaker Michael Moore -- disregard these results owing to data quality issues.

The study finds that the U.S. leads in the field of breast and prostate cancer. France excelled in women's colorectal cancer and Japan in men's colorectal cancer. The news isn't all good here: great discrepancies exist between white and African-Americans. That said, the United States clearly leads other nations in overall survival.

These results aren't completely surprising. Though international comparisons are hard to make, Lancet Oncology published last August a comparison of American and European care, and the U.S. fared better in 13 of the 16 cancers studied.

Americans don't usually hear good news stories about health care. Mr. Moore favorably reviewed British, French and even Cuban health care in the movie "Sicko," showing satisfied patients and happy, chic docs. Paul Krugman wrote last year in the New York Times that: "there's very little evidence that Americans get better health care than the British."

Cancer care there is different than here. Take for instance the country whose health-care system Mr. Krugman likes so much. The Lancet Oncology study finds that five-year survival rates for cancer in men, for example, are 45% in England (slightly higher in Wales, lower in Scotland) but 66% in the U.S.

Why do the British lag behind American survival rates? Screening standards are different. In the United States, internists recommend that men 50 and older get screened for colon cancer; in the National Health Service in the United Kingdom, screening begins at 75. And British patients wait much longer to see specialists. A Clinical Oncology study of British lung cancer treatment found in 2000 that 20% "of potentially curable patients became incurable on the waiting list." Novel drugs offered here often aren't available there; for instance, Avastin, a drug for advanced colon cancer, is prescribed more often in the U.S. than in the UK, by some estimates as much as ten-fold more.

A drug called Temodal is the U.S. standard of care for Sen. Kennedy's type of brain cancer. In Britain, a government body charged with funding decisions -- the euphemistically named NICE, or National Institute for Health and Clinical Excellence -- ruled in 2001 that Temodal wasn't worth the money as a first-line treatment; in 2007, they partially lifted the prohibition. Patients can still get the drug, they just need to pay out of pocket -- for all their cancer care. The National Health Service recently ruled that if patients opt out of one type of care (say by getting Temodal), they opt out of all publicly funded care.

Two cheers, then, for American health care and better cancer outcomes. Rising costs, however, threaten to undermine the economy. Not surprisingly, our debate is shifting to a discussion of getting better value from our health dollars. Just last week, the U.S. House of Representatives held hearings on this topic (full disclosure, I was a witness). Former Sen. Tom Daschle and his co-authors speak at length about "value" in their new book, "Critical: What We Can Do About the Health-Care Crisis." Given his potential role in a future Democratic administration, the book may lay out the first outline of ObamaCare.

What's to be done? Mr. Daschle talks up the idea of a federal health-care board charged with "recommending coverage of those drugs and procedures backed by solid evidence. It would exert influence by ranking services and therapies by their health and cost impacts." The inspiration? Mr. Daschle cites Britain's NICE. The Congressional Budget Office is slated to release a paper on this topic later this year.

Given the Concord results, the CBO may want to hold off on that effort. Value -- like in the other five-sixths of the economy -- will come from competition and choice, not a government committee. But the federal government can take a leadership role in promoting competition. How? By creating greater transparency of prices, releasing more Medicare information on complications and outcomes, encouraging hospitals and clinics to standardize their health records, and slashing regulations that discourage competition. Together, these efforts would make it easier for American patients to seek out excellence. And that seems as American as apple pie and good cancer care.

Dr. Gratzer, a physician, is a senior fellow at the Manhattan Institute. His most recent book, "The Cure: How Capitalism Can Save American Health Care" (Encounter Books, 2006), is now out in paperback.

See all of today's editorials and op-eds, plus video commentary, on Opinion Journal.

I have been leaning towards favoring Romney as Veep for McC, in great part because, unlike McC, he can articulate free market economics pretty well-- but then there is the coming clusterfcuk of Romeny Care-- which will make it hard for McC to challenge BO's promised socialization.=======================

The Price of RomneyCareJuly 29, 2008; Page A16Gearing up for 2009, liberals are eager to claim Massachusetts as a Valhalla of health reform. Their enthusiasm is apparently evidence-proof.

Even Mitt Romney, who should know better, took to these pages recently to proclaim, "Health-care reform is working in Massachusetts." Shortly after Mr. Romney's self-tribute, Governor Deval Patrick wheeled out a new $129 million tax plan to make up for this year's health spending shortfalls. Yet partisans are cheering the cost overruns as a sign of success.

Supporters are exultant because 350,000 people are newly covered since former Governor Romney's parley with Beacon Hill Democrats in 2006; this cuts the state's uninsured rate by about half. That's not the promised "universal" system, but never mind. The ominous news is that only about 18,000 people -- or 5% of the newly insured -- have taken advantage of the "connector," which was supposed to be the plan's free-market innovation linking individuals to private insurers.

Most of this growth in coverage has instead come via a new state entitlement called Commonwealth Care. This provides subsidized insurance to those under 300% of the poverty level, or about $63,000 for a family of four. About 174,000 have joined this low- or no-cost program, a trend that is likely to speed up.

As this public option gets overwhelmed, budget gaskets are blowing everywhere. Mr. Patrick had already bumped up this year's spending to $869 million, $144 million over its original estimate. Liberals duly noted that these tax hikes are necessary because enrollment in Commonwealth Care is much higher than anticipated. But of course more people will have coverage if government gives it to them for free. The problem is that someone has to pay for it.

Thus the extra tab of $129 million, which may need to go higher because it relies on uncertain federal funds from Medicaid. For now, Mr. Patrick wants one-time (yeah, right) charges of $33 million on insurers and $28 million on providers, plus some shuffling of state funds. The balance comes from an estimated $33 million boost in the state's "pay or play" tax: If businesses don't offer "fair and reasonable" insurance to their employees, they get hit.

This is a textbook example of how business taxes evolve into "pay or pay," the first recourse of state-funded health systems. Politicians love levies on business because they disguise the overall bill from voters. But such taxes are merely passed along to workers in the form of reduced take-home pay, since all health costs are part of compensation.

The main reason people are uninsured is because coverage is too expensive. Massachusetts didn't have many options for reforming the way health dollars are laundered in the third-party payment system created by the federal tax code. But it could have helped make insurance cheaper by reforming its private market before defaulting to public programs.

The Bay State has long served up coverage-specific insurance mandates, such as for fertility treatments, which raise costs. Yet in a just-deserts twist, Massachusetts health planners are now reviewing ways to trim mandates because the state is footing more of the bill, even if they didn't care when imposing them on individuals and small business. A state-sponsored study shows that total spending on mandates was $1.32 billion in 2005, or 12% of premiums. The study is devastating despite its pro-mandate slant.

Not that such practical lessons have stopped liberals from joining the Massachusetts parade. They have to gussy up the state's model because the extravagant claim that led to its creation -- that health care will be less expensive if everyone is covered -- is being relentlessly discredited. It's the same claim they want to make when they try to pass a similar plan for the whole country in next year's Congress.

See all of today's editorials and op-eds, plus video commentary, on Opinion Journal.

Pulling the TriggerAugust 2, 2008; Page A10Let's hope Capitol Hill never catches fire. Congress would switch off the alarm and pretend there were no flames. That, at least, was the policy message sent by Speaker Nancy Pelosi and her health-care enforcers when the House voted last week to deactivate a warning that entitlement spending is running amok.

Everybody has known forever that Medicare's spending trend is untenable. The program soaked up 3.2% of GDP and 16% of all federal spending in 2007, and it is expected to grow by 7.4% or more a year over the next decade. The Tom DeLay Republicans made the problem worse with their 2003 prescription drug benefit, but in doing so they felt a twinge, a flicker, a memory flash of fiscal conscience. So as a token gesture Republicans added a "trigger" that was supposed to force some future Congress to address the program's long-term insolvency.

The trigger kicks in if Medicare's Trustees project, for two years in a row, that the program will draw more than 45% of its funding from general government revenue -- instead of from payroll taxes, or premiums and co-pays from beneficiaries. That has happened for the last two years, and probably will every year for the foreseeable future. And when it does, the White House is required to write up "corrective" legislation. Under special procedures, the White House proposal is guaranteed an up-or-down vote in the House, though not the Senate.

The trigger doesn't actually require any cost-saving, much less real discipline. All it does is oblige the political class to nod at Medicare's deteriorating finances. But even that minor annoyance is too much for Democrats, so the House voted 231-184 last Thursday to change the rules to avoid considering President Bush's proposal.

Not that the Administration's proposal is ambitious. It would merely slow the rate of spending growth enough to shut off the 45% trigger. Provisions include moving toward electronic health records and a microincrease in prescription drug premiums for 1.5 million wealthy seniors. The horror!

Congress was free to reject any of this. But a vote might draw attention from the otherwise sleepy Capitol Hill press corps, and Democrats objected even to having the discussion. Liberal health-care maharishi Pete Stark wailed about "a political ploy to foster an unfounded panic," while Majority Leader Steny Hoyer called the trigger "completely arbitrary."

Democrats have tried repeatedly since 2006 to abolish the trigger because it gets in the way of their health-care agenda, even if only a little bit. Barack Obama has plans for a slow-motion roll toward "Medicare for all," the ultimate goal of Democratic health policy. The trigger reminds people of how spendthrift and taxing the budget for Medicare already is -- even when it's reserved only for seniors.

The House vote stalls action until the next Administration, when Democrats will almost certainly dump the trigger entirely.

For those of us who have had quite enough of lipsticked pigs and the politics of personality, here is an effort at discussing the issues from BO's team posting at the WSJ

Why Obama's Health Plan Is Better By DAVID M. CUTLER, J. BRADFORD DELONG and ANN MARIE MARCIARILLEArticle more in Opinion »Email Printer Friendly Share: Yahoo Buzz MySpace Digg Text Size The big threat to growth in the next decade is not oil or food prices, but the rising cost of health care. The doubling of health insurance premiums since 2000 makes employers choose between cutting benefits and hiring fewer workers.

Rising health costs push total employment costs up and wages and benefits down. The result is lost profits and lost wages, in addition to pointless risk, insecurity and a flood of personal bankruptcies.

APSustained growth thus requires successful health-care reform. Barack Obama and John McCain propose to lead us in opposite directions -- and the Obama direction is far superior.

Sen. Obama's proposal will modernize our current system of employer- and government-provided health care, keeping what works well, and making the investments now that will lead to a more efficient medical system. He does this in five ways:

- Learning. One-third of medical costs go for services at best ineffective and at worst harmful. Fifty billion dollars will jump-start the long-overdue information revolution in health care to identify the best providers, treatments and patient management strategies.

- Rewarding. Doctors and hospitals today are paid for performing procedures, not for helping patients. Insurers make money by dumping sick patients, not by keeping people healthy. Mr. Obama proposes to base Medicare and Medicaid reimbursements to hospitals and doctors on patient outcomes (lower cholesterol readings, made and kept follow-up appointments) in a coordinated effort to focus the entire payment system around better health, not just more care.

- Pooling. The Obama plan would give individuals and small firms the option of joining large insurance pools. With large patient pools, a few people incurring high medical costs will not topple the entire system, so insurers would no longer need to waste time, money and resources weeding out the healthy from the sick, and businesses and individuals would no longer have to subject themselves to that costly and stressful process.

- Preventing. In today's health-care market, less than one dollar in 25 goes for prevention, even though preventive services -- regular screenings and healthy lifestyle information -- are among the most cost-effective medical services around. Guaranteeing access to preventive services will improve health and in many cases save money.

- Covering. Controlling long-run health-care costs requires removing the hidden expenses of the uninsured. The reforms described above will lower premiums by $2,500 for the typical family, allowing millions previously priced out of the market to afford insurance.

In addition, tax credits for those still unable to afford private coverage, and the option to buy in to the federal government's benefits system, will ensure that all individuals have access to an affordable, portable alternative at a price they can afford.

Given the current inefficiencies in our system, the impact of the Obama plan will be profound. Besides the $2,500 savings in medical costs for the typical family, according to our research annual business-sector costs will fall by about $140 billion. Our figures suggest that decreasing employer costs by this amount will result in the expansion of employer-provided health insurance to 10 million previously uninsured people.

We know these savings are attainable: other countries have them today. We spend 40% more than other countries such as Canada and Switzeraland on health care -- nearly $1 trillion -- but our health outcomes are no better.

The lower cost of benefits will allow employers to hire some 90,000 low-wage workers currently without jobs because they are currently priced out of the market. It also would pull one and a half million more workers out of low-wage low-benefit and into high-wage high-benefit jobs. Workers currently locked into jobs because they fear losing their health benefits would be able to move to entrepreneurial jobs, or simply work part time.

In contrast, Sen. McCain, who constantly repeats his no-new-taxes promise on the campaign trail, proposes a big tax hike as the solution to our health-care crisis. His plan would raise taxes on workers who receive health benefits, with the idea of encouraging their employers to drop coverage. A study conducted by University of Michigan economist Tom Buchmueller and colleagues published in the journal Health Affairs suggests that the McCain tax hike will lead employers to drop coverage for over 20 million Americans.

What would happen to these people? Mr. McCain will give them a small tax credit, $5,000 for a family and $2,500 for an individual, and tell them to navigate the individual insurance market on their own.

For middle- and lower-income people, the credits are way too small. They are less than half the cost of policies today ($12,000 on average for a family), and are far below the 75% that most employers offering coverage contribute. Further, their value would erode over time, as the credit increases less rapidly than average premiums.

Those already sick are completely out of luck, as individual insurers are free to deny coverage due to pre-existing conditions. Mr. McCain has proposed a high-risk pool for the very sick, but has not put forward the money to make it work.

Even for those healthy enough to gain coverage in the individual insurance market, the screening, marketing and individual underwriting that insurers do to separate healthy from sick boosts premiums by 17% relative to employer-provided insurance, well beyond the help offered by the McCain tax credit.

The immediate consequences of the McCain plan are even worse. The McCain plan is a big tax increase on employers and workers. With the economy in recession, that's the last thing America's businesses need.

Finally, Mr. McCain does nothing to bend the curve of rising health-care costs downward. He does not fund investments in learning, rewarding and preventing. Eliminating state coverage requirements will slash preventive service availability.

The high cost-sharing plans he envisions will similarly discourage preventive care. And as he does nothing about the hidden costs of the uncovered -- expensive ER visits, recurring conditions resulting from inadequate follow-up care.

Everyone agrees our health-care financing system must change. But only one candidate, Barack Obama, has real change we can believe in.

Mr. Cutler is professor of economics at Harvard and an adviser to Barack Obama's presidential campaign. Mr. DeLong is professor of economics at University of California, Berkeley. Ms. Marciarille is adjunct law professor at McGeorge School of Law.

Well here is that Cutler guy again. Does one find it interesting he is a 'Harvard economist' advising how health care should be distributed? I am sure he is a die hard political neutral (sarcasm emphasized). From New England Journal on Cutler and the rest of the "experts". BTW, remember "prevention" is not always synonomous with lower costs.

***Volume 359:1085-1087 September 11, 2008 Number 11 Next

Speaking Truth to Power — The Need for, and Perils of, Health Policy Expertise in the White House

Jacob S. Hacker, Ph.D.

President Harry Truman once famously wished for a one-handed economist, because the ones advising him were forever saying, "On the one hand . . . but on the other hand. . . ." President George W. Bush went one appendage further: "If [these economists] had three hands they'd say, on the one hand, on the other hand, and then on the third hand."1 Yet presidents keep coming back to economists and other policy experts, especially in the fiendishly complex field of health care. Democratic presidential candidate Barack Obama leans on Harvard economist David Cutler; his larger stable of health advisers includes Austin Goolsbee and Jason Furman, both economists. Republican John McCain relies on economics Ph.D. Gail Wilensky, as well as on the former director of the Congressional Budget Office, Douglas Holtz-Eakin, another economist.

Economists are not, of course, the only experts to which presidents and presidential aspirants turn. On health care, Obama and McCain are advised by lawyers, doctors, holders of public-policy degrees, and the occasional noneconomist social scientist. What remains constant is the role these advisers occupy, a role awash in ambiguity, opportunity, and risk. The adviser is the president's ally — in the lingo of organizational economics, an "agent" serving the interests of a "principal." Yet as a bearer of specialized knowledge, the adviser is also responsible to a larger profession, to its values and commitments, and ultimately to the ideal of expertise itself.

The adviser, in short, must both "speak truth to power" and aid in the exercise of power, both offering unbiased intelligence and acting as a very biased assistant. It is fashionable to pretend these two roles are the same, but they are not. An expert adviser has special knowledge, training, and skills — all of which are needed more than ever in the White House. The question is whether these talents can really be used, or be useful, in the bare-knuckles world of American politics — and, more important, whether the values they embody can be upheld when science, advocacy, and democracy collide.

Consider the travails of noted health policy expert Len Nichols. As Hillary Clinton battled for the Democratic nomination, Nichols joined a conference call for reporters set up by her campaign. The topic was an Obama advertisement charging that Clinton would force people to buy insurance "even if they can't afford it." On the call, Nichols likened the ad to "having Nazis march through Skokie" — a depiction the Clinton campaign immediately disavowed. Shortly thereafter, Nichols apologized for letting his "passions" overwhelm him. The head of the New America Foundation, where Nichols works, declared his comments "regrettable," not least because the foundation "does not endorse or advise any campaign in an official capacity."2

Nichols's sin — besides the obvious rhetorical offense — was to cross the line between expert and partisan. Politics is about power more than truth, about winning more than being right. But expertise is about truth more than power, and being right is the whole point. The authority of the expert cannot survive long when expert judgment is seen to hinge on grudges or biases. The abiding concern of the expert adviser is how to maintain independence while acting as a faithful ally and advocate — how to make power serve truth while still serving the principal.

Yet the greater, and more vexing, problem is far less recognized: the limits of expertise itself. When the Clinton administration's health plan died in 1994, many dismissed its health policy advisers as naive. And yet the closest of these advisers were not just highly regarded health policy experts, they were some of the most knowledgeable the White House has ever seen. Paul Starr, who had masterfully dissected the past failure of national health insurance, left Princeton to help write the plan. Scores of other experienced policy gurus — including Len Nichols — lent their wisdom. Even Ira Magaziner, the much-maligned policy wonk who oversaw the president's gargantuan health care task force, had more than a passing familiarity with health and economic policy. All of them had studied the lessons of history — and ended up repeating them anyway.

The modern presidency demands expertise. The rise of a massive, interconnected executive branch, the ever-increasing complexity of public policy, the "permanent campaigns" of contemporary elections, with their endless issues, talking points, and proposals — all make the president's job as much about fostering and managing competing information streams and creating communities of allied expertise as about fulfilling the authoritative role President Bush evocatively termed "the decider." Contemplating Dwight Eisenhower's arrival, Harry Truman foresaw the challenge for the former general as presidential impotence: "He'll sit here, and he'll say, `Do this! Do that!' And nothing will happen."3 But the more basic challenge may be to decide what to do on issues as varied and complex as global warming and stem-cell research, health care financing and financial-market regulation. Here expertise is invaluable, unavoidable — and sometimes, as the failure of the Clinton plan reminds us, perilous.

Health policy experts can do more sophisticated analyses than ever, and there are more of them than ever, too — in policy schools, departments of economics, schools of public health, think tanks, private foundations, and government. But the progress in quality of expertise has not been matched by progress in thinking about the role of the expert or about how policy advice can and should be adapted to the political realities that those receiving advice inevitably confront. Policy experts are brilliant when it comes to designing proposals but often horrible at thinking through the ways in which their proposals will be refracted through the political prism. Subtle visions of policy are wedded to crude caricatures of politics, and, not surprisingly, those visions all too often either fail to become reality or fail to work.

Worse, the expert's claim to authority can undercut the more important wellspring of democratic leadership: the demands and wishes of the people. Experts are habitually disdainful of what ordinary citizens believe. People have opinions; experts have facts. When a well-regarded economist complains that democratic policy choice should be restricted because "irrational" voters endorse all sorts of harmful nostrums — whether trade protection or farm price supports (he might have added health insurance with low deductibles, drug price controls, and free choice of doctors) — he may be out on a limb.4 But the tree is one that many policy experts climb.

Ironically, then, the failure of the Clinton administration's plan was made more, not less, likely by the amount of policy expertise poured into its design. The Clinton advisers sought the ideal policy synthesis. Though aware of political realities, they treated them as problems of policy design, to be managed within the confines of the president's blueprint rather than incorporated into a political strategy that would make the president's goals and ideals, not a 1342-page bill, the guiding light of congressional debate. And the advisers designed the proposal knowing full well that many of its elements, such as greater emphasis on tightly managed health plans, were at odds with what most of the public professed to want. That was a problem for the political consultants, who would try to figure out how to "sell" Americans on what was good for them. The result was a fiasco — and a cautionary tale about the limits of expert presidential advice in an age that demands it.

This time around, health policy advisers — whatever their formal background, and whether two-handed or more Vishnu-like — would do well to take a different tack. We badly need health care experts in the White House who offer advice based on evidence and analysis, not prejudice. But even the best experts need to know when to defer to the political process, to see the purpose of their craft as facilitating democratic debate rather than providing final answers once Americans have decided on the questions.

Winston Churchill once said that "scientists should be on tap, not on top."5 That is a good starting point. But sometimes presidential policy experts should also have the good sense to get out of the way.

Dr. Hacker reports receiving advisory board fees from Pfizer and speaking fees from America's Health Insurance Plans, both of which he reports donating to charity. No other potential conflict of interest relevant to this article was reported.

Source Information

Dr. Hacker is a professor of political science at the University of California at Berkeley, codirector of Berkeley Law School's Center on Health, Economic, and Family Security, Berkeley, CA, and a fellow at the New America Foundation, Washington, DC.

WASHINGTON -- Republican presidential candidate John McCain's health-care plan would make only a small dent in the ranks of the uninsured, at best covering about five million more people, two new reports conclude.

Democratic nominee Barack Obama would cover more people -- eventually adding about 34 million, according to one of those reports, by the nonpartisan Tax Policy Center.

Barack ObamaSen. Obama's plan would be costly, the center concluded: $1.6 trillion over 10 years. Sen. McCain's would cost nearly as much: $1.3 trillion over the same span. The center doesn't give either campaign credit for initiatives to reduce the cost of health care.

The advantages of the McCain plan, according to the reports, are less government regulation, a more generous tax break and, for many, more flexibility and choice in where to buy coverage.

The Tax Policy Center called its estimates for both plans preliminary because neither campaign has put out enough information to provide a full evaluation. Similarly, a pair of studies analyzing the candidates' plans, being published Tuesday in Health Affairs, a peer-reviewed policy journal, found many details lacking. But the campaigns have made clear what direction they would take the health-care system. The differences provide a sharp contrast for voters.

Neither plan would offer universal coverage, though Sen. Obama regularly says his would. Critics of each plan suggest the other would erode the employer-based system that currently covers some 170 million people.

The reports shed new light on the potential and the problems of each plan.

THE OBAMA PLAN:Sen. Obama would give consumers more options, but he would increase federal regulations.

He would create a new government-run plan as well as an "exchange" in which private companies would offer insurance to compete with the government plan. New rules would require that insurance companies provide coverage to everyone, at consistent prices, even those with existing ailments. Parents would be required to cover their children, and large employers would be required to cover their workers or pay a fine.

It amounts to a significant amount of new regulation, health experts Joseph Antos, Gail Wilensky and Hanns Kuttner write in Health Affairs.

"Each of these [new rules] extends the control of government over health insurance, imposing new requirements that will drive up the cost of insurance," they write.

The government-run plan would set a minimum standard for benefits that private plans would have to meet, they explain. Politically, there will be pressure to include generous benefits, they say, and that will lead to high premiums, leaving few options for those who want cheaper, more basic coverage.

It is likely that companies would be required to offer the same generous benefits to their workers, they say -- another increase in government regulation. Still, the impact on the uninsured is significant. Overall, the Tax Policy Center predicts that the Obama plan would reduce the number of uninsured by 18 million people in the first year and by 34 million in 10 years.

THE McCAIN PLAN:Sen. McCain would reduce both state and federal regulations and give consumers more choices about where to buy health insurance.

Current law offers a tax break only to those who get insurance through their jobs. The McCain plan would give a refundable tax credit to all who find coverage: $2,500 per person or $5,000 per family. In trade, workers would pay income taxes on the value of health insurance as part of their compensation.

But, unlike a similar plan put forth by President George W. Bush last year, health benefits still would be exempt from the payroll tax paid by workers and employers, and that is why the McCain plan is more expensive than Mr. Bush's, said Len Burman, director of the Tax Policy Center. Because people could buy insurance on their own, some would leave the employer-sponsored system, especially young and healthy people who can get a better deal on their own. Older, sicker people are likely to face problems buying coverage.

Overall, the Tax Policy Center and the four academics writing in Health Affairs project that about 20 million would leave employer-sponsored coverage, while about 21 million people would be newly covered on the open market. That is a net increase of about one million insured people.

"Many employers would be quick to drop health benefits in response to a major policy change, such as the McCain plan, that greatly altered the business case for offering benefits," the article concludes. The Tax Policy Center projects that the number of newly insured Americans could climb in future years and perhaps reach five million people before dropping again.

The Health Affairs article, whose lead author is Thomas Buchmueller of the University of Michigan, finds other problems with the McCain plan. Because administrative costs are higher on the open market, where insurers evaluate customers individually, he predicts that coverage would be more expensive but less generous.

The McCain plan would allow consumers to buy insurance across state lines. That would give people more choices, but it also would undermine state laws that mandate certain benefits and provide various consumer protections.

"According to an August 2008 study published in Lancet Oncology, the renowned British medical journal, Americans have a better than five-year survival rate for 13 of the 16 most prominent cancers when compared with their European and Canadian counterparts.

With breast cancer, for instance, the survival rate among American women is 83.9 percent. For women in Britain, it’s just 69.7 percent. For men with prostate cancer, the survival rate is 91.9 percent here but just 73.7 percent in France and 51.1 percent in Britain.

American men and women are more than 35 percent more likely to survive colon cancer than their British counterparts."

By Sally C. PipesSpecial to the Examiner | 8/23/08 7:35 PM With Democrats convinced 2008 is their year, the campaign trail is awash with promises to make universal health care a reality by the end of the next president’s first term.

The basic argument of those who support a government takeover of the health care system is familiar. As New York Times columnist Paul Krugman once put it, “America’s health care system spends more, for worse results, than that of any other advanced country.”

Krugman’s line has been repeated so often it’s considered gospel truth in most public debates — people rarely check to see if it matches the facts. As the American humorist Josh Billings quipped, “the problem with the world ain’t ignorance, it’s the things people know that just ain’t so.”

If they did, they’d probably be surprised. Socialized health care isn’t all it’s cracked up to be.

Take the much-vaunted Canadian system. More than 825,000 Canadian citizens are currently on waiting lists for surgery and other necessary treatments. Fifteen years ago, the average wait between a referral from a primary-care doctor to treatment by a specialist was around nine weeks. Today, that wait is over 16 weeks.

That’s almost double what doctors consider clinically reasonable. As Canadian physician Brian Day explained to The New York Times, Canada “is a country in which dogs can get a hip replacement in under a week and in which humans can wait two to three years.”In part, these waits are due to a doctor shortage. According to the Organization for Economic Cooperation and Development, Canada ranks 24th out of 28 countries in doctors per thousand people.

Why so few doctors? Over the past decade, about 11 percent of physicians trained in Canadian medical schools have moved to the United States. That’s because doctors’ salaries in Canada are negotiated, set and paid for by provincial governments and held down by cost-conscious budget analysts. Today, in fact, the average Canadian doctor earns only 42 percent of what a doctor earns in the United States.

Canada also limits access to common medical technologies. When compared with other OECD countries, Canada is 13th out of 24 in access to magnetic resonance imagings, 18th of 24 in access to computed tomography scanners, and seventh of 17 in access to mammograms.

The problems plaguing Canada are characteristic of all universal health care systems.

In Britain, more than 1 million sick citizens are currently waiting for hospital admission. Another 200,000 are waiting just to get on a waiting list. Each year, Britain’s National Health Service cancels around 100,000 operations.

Britain even has a government agency explicitly tasked with limiting people’s access to prescription drugs. Euphemistically called the National Institute for Health and Clinical Effectiveness, the agency determines which treatments the British health care system covers. More often than not, saving money takes priority over saving lives.

In 2008, for instance, NICE refused to approve the lung cancer drug Tarceva. Despite numerous studies showing that the drug significantly prolongs the life of cancer patients — and the unanimous endorsement of lung cancer specialists throughout the United Kingdom — NICE determined that the drug was too expensive to cover relative to its effectiveness. As of August 2008, England is one of only three countries in Western Europe that denies citizens access to Tarceva.

Britain’s behavior is typical — every European government rations drugs to save money. Eighty-five new drugs hit the U.S. market between 1998 and 2002. During that same time period, only 44 of those drugs became available in Europe.

The evidence clearly indicates that patients under socialized medicine are suffering. Why, then, do countries with government-run health care consistently outrank the United States on international quality surveys?

It’s not because the American health care system is inferior. It’s because these surveys use deeply flawed metrics that don’t reflect health care quality.

Case in point: The World Health Organization rankings of overall health system performance placed the United States 37th out of 191 countries. That’s behind not only Canada, Britain and France, but even countries like Costa Rica, Morocco and Cyprus.

Life expectancy accounted for 25 percent of a nation’s WHO ranking. But life expectancy is the function of a variety of factors. Medical care is just one of them. Just as important are a nation’s homicide rate, the number of accidents, diet trends, ethnic diversity and much more.

Another factor accounting for 25 percent of a nation’s ranking was “distribution of health,” or fairness. By this logic, treating everyone exactly the same is more important than treating people well. So long as everyone is equal — even if they’re equally miserable — a nation will do quite well in the WHO rankings.

In measuring the quality of a health care system, what really matters is how well it serves those who are sick. And it’s here that America really excels.

According to an August 2008 study published in Lancet Oncology, the renowned British medical journal, Americans have a better than five-year survival rate for 13 of the 16 most prominent cancers when compared with their European and Canadian counterparts.

With breast cancer, for instance, the survival rate among American women is 83.9 percent. For women in Britain, it’s just 69.7 percent. For men with prostate cancer, the survival rate is 91.9 percent here but just 73.7 percent in France and 51.1 percent in Britain.

American men and women are more than 35 percent more likely to survive colon cancer than their British counterparts.

It’s no wonder then that foreign dignitaries living in countries with socialized health care systems routinely come to this country when they need top-flight medical treatment.

When Italian Prime Minister Silvio Berlusconi needed heart surgery in 2006, he traveled to the Cleveland Clinic — often considered America’s best hospital for cardiac care. When Canadian Member of Parliament Belinda Stronach, who had denounced a two-tier health care system for Canadians, needed breast cancer surgery herself in 2007, she headed to a California hospital and paid out of pocket.

So much for the “free” health care they could have received at home.

As for the supposed cost advantages of socialized medicine? Those are illusory, too. True, other developed nations may spend less on health care as a percentage of gross domestic product than the United States does — but so does Sudan. Without considering value, such statistical evaluations are worthless.

And one of the primary reasons health care costs more in America is that we are a wealthy country that demands the best. And, we’re investing a lot more in medical research.

The United States produces over half of the $175 billion in health care technology products purchased globally. In 2004, the federal government funded medical research to the tune of $18.4 billion. By contrast, the European Union — which has a significantly larger population than the United States — allocated funds equal to just $3.7 billion for medical research.

Between 1999 and 2005, the United States was responsible for 71 percent of the sales of new pharmaceutical drugs. The next two largest pharmaceutical markets — Japan and Germany — account for just 4 percent each.

While no one can deny that there are significant problems in the American health care system, overall it provides exceptional value. The ideologues who claim we’d be better off under socialized medicine are massively wrong. Government-run health care has proven to be heartless and uncaring — and the inferior treatments it provides come with a very steep price tag.

Crafty I suppose you are self employed, do you have any health insurance tips for someone looking to buy their own health insurance. The policy I have through work sucks, so I am looking around, to see if I can do better on my own.

"Lets say I don't have health care because I can't afford it. Would socialized health care be better or worse for me?"---------Free lunch may taste good, but in the long view, I think you are worse off. Just my opinion. It really depends on how you feel about mandating someone else to pay your basic living expenses.

'Can't afford it' has two components, income and the (artificially) high cost of health care. Poor people in America already have free health care. It's amazing to see how they use the money they save on other things.

Why are health care expenses artificially high? Third party pay. There is a disconnect between the user of the service and the payer of the service that removes market spending discipline. Price is the most efficient way of allocating a scarce resource. Unfortunately, the more important the resource the more we turn to less efficient methods.

In the long run you are right Doug... but I don't think many people consider that.

I am a single guy, with no dependents... and I bring in a good wage... I am already paying for plenty of other peoples basic living expenses so I feel you there as well. I am not sure that poor people are really capable of saving money. If they could they would not really be poor would they? I guess that is a little off topic...

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When life gives you lemons make lemonadeWhen life gives you hemlock, do NOT make hemlockade!

Crafty I suppose you are self employed, do you have any health insurance tips for someone looking to buy their own health insurance. The policy I have through work sucks, so I am looking around, to see if I can do better on my own.

In a previous life, I was an Employee Benefit Consultant for a very large Employee Benefit Consulting Firm. Mostly large to very large clients, but for buying health insurance, the concept is the same. I guess Tankerdriver the question is, "Are you healthy?" No one can predict the future, but today, are you healthy? And, given your genes, are you healthy? And finally, it depends on age. But let's assume you are healthy and reasonably young (under 40) then Crafty is right, an HSA is the way to go. Why? You can save a lot of money tax deferred (don't forget to put away the money for a rainy day), you can buy a "quality" medical plan" and it's portable. Portable is important. The plan you belong to, your employer's plan, you must remember it isn't yours. Yes, if you quit or a laid off, you have COBRA for 18 maybe 36 months, but after that you have zero; not good if you have a heart attack, cancer, etc. After COBRA runs out, if you are healthy, fine, but if not, you can't buy health insurance at any price when you really need it. The counter argument is that your employer's plan usually offers pretty good low deductible benefits (maybe you have a choice of plans?) and it is free (employer paid) or minimal cost to you. If you truly have job security, i.e. police, fire, government employee, etc. maybe that is the way to go, but...

I have an excellent quality, albeit expensive HSA. I must pay the first $2400.00 out of my own pocket (an incentive to stay healthy) but that is ok because overall I have been blessed with good health. I rarely need to go to the doctor. And I am self employed. And if something happens I want to go to the "best" doctors and hospitals, not the ones on a limited list. But if I were you and had an ongoing or chronic problem, then I might consider joining a group plan if I had that choice. Also, note, as you get older, you HSA premium will rise becoming much more expensive than a group plan. I pay a small fortune for a plan I (almost) never use yet I don't consider being without it. You never know and while I can afford $2400.00 I can't afford $500,000+ for a serious illness. It happens.

As for "poor people in America already have free health care" that is true, albeit a very poor substitute for quality care. Many/most doctors, especially your top tier will not treat non pay patients. And many top hospitals will reject that patient. And you might get the CT Scan, but they will say you really don't need the MRI (too expensive is what they mean) and you want the new cancer drug, well forget it, it's too expensive. The quality of care is second class, no third class or worse. it's not only my opinion, although from personal experience I have been treated different when they thought I didn't have but later found out I did have good coverage, but numerous studies and books show the disparity of quality care. Is that right? Is that fair? I don't know, I guess it's a different subject.

My inclination is that No, not every deserves the same level of healthcare... but I say that with caution. Although some people are no doubt in the situation they are in by choice, you can't choose who your parents are, and your parents more or less determine what type of healthcare you get as a child.

That waitress that works 60 hours a week to raise her kids might not be able to afford the best healthcare... but does that mean she deserves it less than a wealthy banker? What about a convicted felon?

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When life gives you lemons make lemonadeWhen life gives you hemlock, do NOT make hemlockade!